Objective To investigate the impact of linear accelerator radiotherapy combined with chemotherapy on short-term efficacy, survival outcomes, symptom improvement, and adverse reactions in patients with locally advanced esophageal cancer. Methods A total of 60 patients with locally advanced esophageal cancer who received treatment at the Department of Radiotherapy, The Second Affiliated Hospital of Zhejiang University School of Medicine from January 2020 to December 2021 were randomly divided into two groups: the study group and the control group, with 30 patients in each group. The study group received intensity-modulated radiotherapy (IMRT) using a linear accelerator combined with a TP chemotherapy regimen (paclitaxel+cisplatin), while the control group received conventional three-dimensional conformal radiotherapy (3D-CRT) combined with the same chemotherapy regimen. The short-term efficacy, survival outcomes, improvement of dysphagia, and treatment-related adverse reactions were compared between the two groups. Results The objective response rate (ORR) in the study group was significantly higher than that in the control group (76.7% vs. 50.0%, P=0.032). The study group had significantly longer median progression-free survival (PFS) and median overall survival (OS) (12.3 months and 18.6 months, respectively) compared with the control group (8.7 months and 13.2 months, respectively) (both P <0.05). The symptom improvement rate of dysphagia after treatment in the study group was significantly higher than that in the control group (83.3% vs. 60.0%) (P=0.045). There were no statistically significant differences between the two groups in the incidence of major treatment-related adverse reactions (all P > 0.05). Conclusion Linear accelerator radiotherapy combined with chemotherapy can significantly improve short-term efficacy and quality of life in patients with locally advanced esophageal cancer, alleviate symptoms of dysphagia, and does not increase treatment-related adverse reactions. This study provides a feasible solution for chemoradiotherapy of locally advanced esophageal cancer and considers the potential for precision medicine to be applied in tumour radiotherapy.