In patients with tonsil cancer the risk of retropharyngeal metastases is negligible in the presence of clinically T1-2, N0-N2a disease and negative CT and PET-CT. We estimate that 40% of patients meet these criteria and may safely forego treatment of the retropharyngeal nodes. Approximately 10% of patients will have positive imaging and we recommend retropharyngeal node dissection at the time of surgery to treat macroscopic disease. In the remaining patients at risk for retropharyngeal node involvement, adjuvant radiotherapy is generally indicated based on other adverse features, and these nodes may be incorporated into the treatment field.