Primary cancers arising in the subglottic region are rare and are characterized by a long asymptomatic phase. More frequently the subglottis is reached by tumors arising in the glottis or even the supraglottis through invasion of the paraglottic space. Involvement of the subglottis is associated with a relatively high frequency of stomal recurrences due to a peculiar lymphatic spread to the paratracheal nodes. We analyzed a retrospective series of 68 patients with squamous cell carcinoma of the larynx extending to the subglottis region submitted to total simple laryngectomy or total laryngectomy enlarged with hemithyroidectomy and dissection of level VI nodes (HT/SPD). Overall median follow-up is 46 months. Subglottic extension was correctly diagnosed before operation in only 13/68 patients, however the resection margins, systematically determined by the pathologist, were in every case negative. Stomal relapses in laryngectomized patients without HT/SPD have been more frequent (0.55% rate per month) than in those treated with laryngectomy and HT/SPD (0.07% rate per month). It is concluded that CT should be routinely applied in preoperative staging in order to estimate the extension of the neoplasia and surgery should always include hemithyroidectomy and dissection of the homolateral paratracheal nodes when there is even minimal involvement of the subglottis. Moreover, the high incidence of second tumors in our series is noteworthy; such patients might benefit from chemopreventive therapy.