The aim of this study was to define the role of elective neck dissection in patients with a second N0 head and neck squamous cell carcinoma (HNSCC). We carried out a retrospective study in 74 patients with a second N0 HNSCC treated with an elective neck dissection. Thirteen patients (17.6%) had occult neck node metastases. The risk of occult neck nodes was low for patients with a second glottic tumor (0%), and for patients with non-glottic T1-T2 tumors who had received previous radiotherapy in the neck (5.3%). Patients with non-glottic locally advanced tumors (T3-T4) and non-glottic T1-T2 tumors who had not received previous radiotherapy in the neck had a risk of occult neck nodes of 28.1 and 33.3%, respectively. Elective neck dissection could be omitted in patients with glottic tumors and in patients with an early tumor (T1-T2) who had received previous radiotherapy in the neck.