Treatment of squamous cell carcinoma of the tonsil involves primary radiotherapy (RT) or surgical resection. Historically, if radiotherapy was the primary or adjuvant treatment modality, most of the bilateral retropharyngeal lymph nodes (RPLN) were treated electively with a therapeutic dose for subclinical disease, regardless of if radiographically pathologic lymph nodes were seen on initial diagnostic imaging. De-escalation strategies include the incorporation of transoral surgery (TOS) with the goal to either eliminate or reduce the dose of adjuvant RT or chemotherapy. TOS does not include elective removal of the RPLNs and no guideline or outcome paper recommends adjuvant RT specifically to electively treat RPLNs. In this topic discussion, we discuss pertinent literature and suggest management decisions. The management decisions discussed in this topic discussion pertain only to tonsillar primaries and not those of the soft palate or base of tongue.
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