Abstract Background Cervical lymphatic spread in laryngeal carcinoma most commonly involves levels II–IV. Metastatic involvement of level I nodes is considered uncommon; therefore, this level is frequently spared during selective neck dissection in clinically node-negative (N0) necks. However, altered lymphatic drainage following surgery or radiotherapy may predispose to atypical recurrence patterns. Objective To describe four patients who developed isolated level I nodal recurrence after total laryngectomy with selective neck dissection that spared level I nodes, and to discuss the possible oncologic implications. Methods A retrospective case series of four patients treated at the Department of Otorhinolaryngology–Head and Neck Surgery, Kasr Al‑Ainy Faculty of Medicine, Cairo University. Clinical presentation, initial treatment, adjuvant therapy, imaging findings, and outcomes were reviewed. Results All patients developed delayed recurrence in level I nodes despite previous selective neck dissection. Time to recurrence ranged from 9 months to 2 years. Salvage surgery or palliative therapy was provided according to resectability and general condition. Conclusion Although level I metastasis from laryngeal carcinoma is uncommon, recurrence may occur, particularly in advanced tumors or after alteration of normal lymphatic pathways. Level I preservation should therefore be considered cautiously in selected high-risk patients. Larger studies are required to determine whether routine inclusion of level I is warranted.
Metwaly et al. (2026) studied this question.