This is an analysis of 25 patients with carcinoma of the skin of the head and neck with clinical evidence of perineural invasion, who were managed with curative intent by radiotherapy alone (16) or surgery and radiotherapy (9). All patients had a minimum of 5 years of follow-up. Local control following treatment was observed in 20% of patients treated with radiotherapy alone and 38% of those treated with surgery and radiotherapy. Local control was diminished for recurrent lesions and for tumors that also invaded bone and/or cartilage. The 5-year absolute survival rates were 31% for patients treated with radiotherapy alone and 33% for those in the combined-treatment group. The incidence of significant complications was similar: 25% with radiotherapy alone and 33% with surgery and adjuvant radiotherapy.