The need to treat the neck in patients with a small primary cancer in the tongue remains controversial. Twenty-eight patients with stage I or II oral tongue squamous carcinomas were retrospectively reviewed. They had not received previous treatment. The tongue primary was excised via the transoral route and the neck was observed closely during follow-up. Thirteen patients developed ipsilateral nodal metastases during follow-up, three of whom also had simultaneous recurrence at the primary site. An additional patient had recurrence at the primary site alone. The incidence of occult neck metastasis was 42% (10 of 24). No tumor-related death occurred in the group without nodal metastasis. The salvage rate after appearance of nodal metastasis was 30%. In oral tongue cancers, elective neck treatment should be considered regardless of a small primary and negative neck examination because of the high incidence of occult nodal metastasis and the poor outcome after salvage treatment. © 1992 John Wiley & Sons, Inc.