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For patients with clinically node-positive oropharynx cancer treated with radiotherapy, planned neck dissection is controversial. We investigated whether neck surgery after radiation reduces nodal recurrence. Between 1970 and 1995, 263 patients at Massachusetts General Hospital received radiotherapy for clinically node-positive base of tongue or tonsil carcinomas. Patients received three different types of treatment: neck surgery followed by radiation (SR)—50 patients; radiation alone (RT)—160 patients; and radiation followed by surgery (RS)—53 patients. Median patient follow-up was 28 months. SR patients have an 84% complete response (CR) rate, RT patients 76%, and RS patients 13%. In multivariate analysis, among patients with a CR, the three treatment groups have the same regional control rates. Among patients with an incomplete response, the RS treatment group is 67% (p < 0.01) and 86% (p < 0.01) less likely to have recurrence than the RT and SR groups, respectively. Neck dissection after radiation therapy improves regional control for patients without a complete clinical response to radiation therapy but not for those with a CR. Despite higher CR rates, neck dissection before radiation confers no regional control benefit. We therefore recommend that primary radiotherapy with neck dissection be reserved for those without a complete clinical response.