Abstract: The application of intensity-modulated radiation therapy (IMRT) has significantly improved the overall survival and local control rates for patients with nasopharyngeal carcinoma (NPC). However, there remains a local recurrence rate of approximately 10%, with salvage radiation therapy potentially leading to severe complications. In recent years, endoscopic surgery has become the primary surgical treatment for recurrent NPC. Nonetheless, the lesion sites of recurrent NPC are complex and risky, and there has yet to be an established expert consensus on surgical treatment strategies. Surgery for recurrent NPC continues to present significant challenges and is a critical topic within skull base surgery. This article will review several aspects of surgical treatment for NPC, including the efficacy of endoscopic surgery for recurrent NPC, surgical approaches for local lymph node recurrence, new surgical T staging and endoscopic surgery classification, strategies for managing positive surgical margins post-operation, internal carotid artery management protocols, skull base reconstruction methods, the redefinition of criteria for resectability, the treatment of radiation-induced necrosis of the skull base, and reflections on the surgical treatment of primary NPC. Additionally, it will provide insights into the future directions of surgical treatment for NPC.