Objectives <p>The optimal management of cervical lymph nodes in tongue squamous cell carcinoma (TSCC) remains controversial, given the need to balance oncological safety with functional preservation. This study aimed to identify clinicopathological predictors of recurrence and survival to improve patient-specific strategies for neck management.</p> Materials and methods <p>This retrospective study included 74 patients with histologically confirmed TSCC. All patients underwent standardized staging including [¹⁸F] FDG PET/CT. Predictor variables included clinical tumor size (cT), suspicious cervical nodes (cN) and number of metastatic lymph nodes (pN). Outcome parameters comprised overall survival (OS), recurrence-free survival (RFS), local recurrence, regional recurrence and contralateral nodal recurrence and disease-specific mortality.</p> Results <p>The 1- and 5-year OS rates were 97% and 83%, respectively, and RFS rates were 80% and 61%. Perineural invasion (PNI) was significantly associated with inferior OS (<i>p</i> = 0.03) and RFS (<i>p</i> = 0.021). The number of metastatic lymph nodes independently predicted mortality (OR = 1.5; 95% CI: 1.08–2.16; <i>p</i> = 0.018). Each additional suspicious node on [¹⁸F] FDG PET/CT increased the odds of advanced nodal stage (pN2b OR = 2.49; <i>p</i> = 0.008; pN3b OR = 2.65; <i>p</i> = 0.001). Contralateral lymphatic drainage occurred in 21.6% and metastases in 5.4% of patients.</p> Conclusions <p>Preoperative [¹⁸F] FDG PET/CT nodal burden, tumor size and contralateral drainage patterns are potential predictors for patient-specific tailoring of the extent and laterality of neck dissection in TSCC.</p> Clinical relevance <p>Quantifying nodal burden and integrating biological factors such as perineural invasion and sex-related differences may refine individualized surgical strategies and improve prognostic accuracy beyond conventional TNM staging.</p>