Neck Management in Malignant Parotid Tumors: A Retrospective Analysis of Elective Neck Dissection Indications and Outcomes

<b>Background/Objectives:</b> Management of the clinically negative neck in malignant parotid tumors remains controversial. We aimed to identify clinicopathologic predictors of nodal involvement and to evaluate whether elective neck dissection (END) improves disease-free survival (DFS) versus observation in cN0 patients. <b>Methods:</b> We performed a retrospective cohort study of adults undergoing surgery for malignant parotid tumors at a single tertiary center (2013-2023) with ≥24 months of follow-up. Collected variables included demographics, tumor T category and histologic grade (AJCC 8th), parotidectomy type, neck management [END vs. therapeutic neck dissection (TND) vs. observation], lymph node yield, and outcomes. Associations were tested with Fisher's exact tests; disease-free survival (DFS) was analyzed using Kaplan-Meier curves, log-rank tests and an exploratory multivariable Cox proportional hazards model. <b>Results:</b> Seventy-four patients were included (mean age 54.3 years; 12.2% preoperative facial nerve impairment). Parotidectomy was partial (41.9%), total (31.1%), radical (21.6%), or extended (5.4%). Neck dissection was performed in 40.5% (END 23.0%; TND 17.6%). Overall pathologic nodal positivity (pN+) was 18.9%. T3-T4 tumors had greater odds of nodal metastasis than T1-T2 (OR 10.58; <i>p</i> < 0.05). Among cN0 patients, occult metastasis was 17.6%; notably, all high-grade cN0 tumors that underwent END were pN+. Intraparotid nodal metastases occurred in 28.6% and always co-occurred with cervical metastases. DFS did not differ significantly between cN0 patients managed with END versus observation (log-rank <i>p</i> > 0.05). Patients with pN0 had superior DFS versus pN+ (<i>p</i> < 0.05). Lymph node yield groupings (0-17 vs. 18-40 vs. >40) were not associated with recurrences. In the exploratory multivariable Cox model, high/intermediate-grade and T3-T4 tumors and nodal positivity were associated with reduced DFS. <b>Conclusions:</b> Higher T category and high/intermediate grade strongly predict nodal involvement, and pN+ status portends worse DFS. Although END did not show a DFS advantage over observation in cN0 patients, the 17.6% occult metastasis rate-especially in high-grade disease-and the linkage between intraparotid and cervical metastases support a risk-adapted END strategy and intraoperative assessment of intraparotid nodes to guide neck management.