The neck matters: optimising lymph node management in laryngeal cancer.

Objective: Laryngeal squamous cell carcinoma (LSCC) accounts for nearly one quarter of head and neck malignancies, with cervical nodal status representing the strongest prognostic factor. This review aims to summarise evidence on neck management across different clinical scenarios. Methods: A narrative review of PubMed, Scopus, and Web of Science was conducted up to July 2025. Original studies, systematic reviews, meta-analyses, and clinical guidelines were included. Data were analysed according to clinical setting: cN0, cN+, rcN+, and rcN0. Results: In primary cN0 LSCC, the risk of occult nodal disease is site-dependent. Supraglottic tumours show the highest incidence (20-50%, > 50% in T3-T4), supporting elective bilateral selective neck dissection (SND) of levels II-IV, with level VI in selected cases. Early glottic tumours rarely metastasise (< 10%) and may be observed, while advanced glottic and subglottic tumours show higher risk (15-30%), justifying elective treatment. In cN+ disease, SND is indicated for N1-N2 and modified radical neck dissection for N3. Regional recurrence occurs in 15-25% of cases. In rcN+ disease, salvage SND provides regional control comparable to comprehensive dissection with lower morbidity. The role of elective dissection in rcN0 remains controversial despite occult metastasis rates > 20% in high-risk tumours. Conclusions: Neck management in LSCC should be adapted to risk: elective treatment is essential in high-risk cN0 disease, therapeutic dissection remains standard in cN+, and salvage SND is effective in rcN+, while elective treatment in rcN0 should be reserved for selected cases.