**4. Treatment**

Different treatment strategies, surgery, and nonoperative treatment were adopted according to the scope of the tumor. However, the existing literature has limitations due to the shortage of multicenter large sample randomized controlled tests. In the setting of unbalanced development in economic, academic, and medical conditions in different regions, remain in the effect of treatment, it is difficult to unify the mode of diagnosis and treatment, and the differences are present in curative effects. The general principle is to improve the postoperative life quality for patients on the premise of ensuring that the tumor is removed completely. Treatment selection requires optimizing swallowing and speaking functions to prevent a long-term aspiration and tracheostomy/G- tube dependence and acquire a balance between disease cure and anatomical preservation of tissue [19, 51].

In addition to taking effective measures to accurately determine the scope and clinical stage of the tumor, multidisciplinary treatment (MDT) should also run through the whole process of tumor diagnosis, treatment, and rehabilitation to gain optimal rehabilitation effect.

## **4.1 Early-stage tumor (T1/T2 with N0/N1)**

#### *4.1.1 Primary radiotherapy or open surgical procedures*

Refinement in technology has improved radiation oncology across the past 20 years. The newer "more precise" techniques, such as intensity-modulated radiotherapy, compared with standard therapy, ameliorate locoregional control of hypopharyngeal carcinoma [52–54]. These techniques extend the concentration of dose to the primary tumor and concomitantly lower collateral injuries to normal tissues [53]. The results of the retrospective analysis showed the similarity between the long-term survival prognosis of primary radiotherapy and laryngectomy [55–57]. However, prospective evidence is limited for the similarity between locoregional control and survival rates [46, 58, 59]. Postradiation local control rate was achieved in 68–90% of patients with T1 tumors and approximately 75% cases in T2 lesions [58, 60–62]. The goal of radiation with concurrent chemotherapy is to acquire speaking and swallowing functional of invaded area and laryngeal preservation rates for five years above 70% [52, 63, 64]. Radical radiation-related injuries to the neck tissues need to be taken seriously, including substantial acute and late

**Figure 6.** *Radiotherapy toxicity of neck.*

toxicity (**Figure 6**). Although a majority of acute toxicities are temporary (such as radiation-related dermatitis usually alleviated within 6–12 weeks of treatment), permanent xerostomia at least partly is present invariably. Post-radiotherapy complications such as aspiration and chronic dysphagia may also occur in some cases, depending on the permanent feeding tube. The incidence is growing associated with intensive protocols (e.g., concurrent chemoradiotherapy). Therefore, effective quality assurance mechanisms and appropriate expertise are needed to be established to limit treatment-related toxicity and optimize results.

The skin injury often occurs during radiotherapy, including red swollen of skin, painful blisters, and pigmentation.

Open surgery is also an available approach for early-stage lesions compared with radiotherapy [65]. The posterior pharynx tumors can be excised through the transhyoid approach [66, 67]. Meanwhile, reservation of the internal branch of the superior laryngeal nerve is necessary. The transhyoid approach is critical for the disease that cannot be exposed transorally, especially in advanced tumors [51]. The more noticeable problem is that the postoperative T1T2 diseases with high-risk factors (e.g., positive margins, positive lymph nodes, extracapsular tumor extension) and locally advanced tumors should perform radiotherapy [68].
