Background: Patients with head and neck cancer (HNC) benefit from nutritional support by means of PEG tubes, but endoscopy may be impossible when there is partial or complete trismus and/or stenosis or occlusion of the upper aerodigestive tract. Methods: PEG tubes were placed in 277 patients with HNC. Oral insertion of an endoscope into the esophagus was impossible in 27 patients. Transnasal endoscopy was performed (n = 4). In the cases of high-grade tumor obstruction, the endoscope was introduced into the esophagus through a straight laryngoscope (n = 9). When upper aerodigestive tract occlusion was present, endoscopy with PEG placement was successfully performed during surgery by means of the opened pharynx after tumor resection (n = 12). Results: In 25 of the 27 cases PEG tubes could be placed by using the above alternative techniques. There were no immediate complications, and no complications occurred within 30 days of PEG placement. Conclusions: Transnasal, straight laryngoscopic, or intraoperative open endoscopy can improve the success rate for PEG tube placement in patients with HNC.