Aim Treatment strategies for locally advanced hypopharyngeal cancer are determined based on tumor extent, curability, and patient background. Chemoradiotherapy (CRT) is often selected with the aim of laryngeal preservation; however, some patients cannot maintain adequate laryngeal function after treatment because of swallowing dysfunction or complications. This study aimed to compare treatment outcomes and post-treatment laryngeal function between surgery and CRT at our institution. Methods We retrospectively reviewed 44 patients with locally advanced hypopharyngeal cancer who underwent curative treatment between January 2018 and October 2024. Patients were divided into a surgery group and a CRT group according to initial treatment. Overall survival (OS), disease-free survival (DFS), and post-treatment laryngeal function were compared. Results Patient age ranged from 37 to 86 years (median 66.5); 36 were men and 8 were women. T classification was T3 in 15 patients and T4 in 29 patients. Fourteen patients underwent surgery and 30 received CRT. The 2-year OS rates were 85.7% in the surgery group and 63.3% in the CRT group, and the 2-year DFS rates were 32.1% and 37.9%, respectively, with no significant differences (OS p=0.125; DFS p=0.675). Dependence on non-oral nutrition was observed in none of the surgery group but in 33.3% of the CRT group (p=0.018). Aspiration pneumonia occurred in 40.0% of the CRT group but in none of the surgery group (p=0.008). In the CRT group, 13.3% had a persistent tracheostoma, and only 33.3% were recurrence-free, without tracheostomy tube, and able to take oral nutrition two years after treatment. Conclusion Although DFS did not differ significantly between groups, OS tended to be better in the surgery group. Non-oral nutrition dependence and aspiration pneumonia were significantly more frequent after CRT. Even when CRT is performed for laryngeal preservation, functional laryngeal preservation may not be achieved.