Background <p>Transoral endoscopic head and neck surgery is an important modality in hypopharyngeal carcinoma therapy. Minimally invasive techniques and nerve protection are important components of Enhanced Recovery After Surgery principles. However, the limited surgical space and the challenges in identifying the internal branch of the superior laryngeal nerve (ibSLN) pose difficulties during this procedure. This study investigated the effects of preserving the ibSLN during transoral laser surgery on the postoperative swallowing rehabilitation of patients diagnosed with pyriform sinus carcinoma.</p> Methods <p>A prospective cohort study with a retrospective control group was performed, including 42 patients with pyriform sinus carcinoma who had previously undergone transoral laser surgery. The participants were categorized into the ibSLN dissection and control groups. In the ibSLN dissection group, the ibSLN was exposed and dissected without nerve lesions. Traditional transoral surgery without proactive ibSLN dissection was performed in the control group. Demographics, operative data, postoperative swallowing function, tube removal time, and postoperative hospitalization time were evaluated and compared between both groups.</p> Results <p>Although the surgery time was longer in the ibSLN dissection group, the normal food intake, tube removal time, and postoperative hospitalization times were significantly shorter than those in the control group (<i>P</i> &lt; 0.05). The MD Anderson Dysphagia Inventory (MDADI) scores after surgery significantly improved in the ibSLN dissection group. At 14 days post-surgery, significant improvements were observed in the four MDADI subset scores: global (<i>P</i> &lt; 0.001), emotional (<i>P</i> &lt; 0.05), functional (<i>P</i> &lt; 0.05), and physical (<i>P</i> &lt; 0.05). The postoperative water swallowing test showed a significantly faster swallowing speed in the ibSLN dissection group compared to the control group (<i>P</i> &lt; 0.001). Fiberoptic endoscopic evaluation of swallowing showed a reduction in the epiglottic mobility impairment, aspiration, and residue in the pyriform fossa in the ibSLN dissection group, although the difference was not statistically significant.</p> Conclusions <p>Identification and dissection of the ibSLN can be successfully performed during transoral laser surgery in patients with pyriform sinus carcinoma. ibSLN dissection during transoral laser surgery has the potential to mitigate the risk of ibSLN damage, thereby facilitating enhanced recovery after surgery.</p>