Elective neck dissection has long been a subject of debate among surgeons. The proponents of elective neck dissection base their rationale on studies that show a 30% incidence of occult disease in those situations for which elective neck dissection is recommended. One hundred eighty-two patients with advanced stages of squamous cell carcinoma of the head and neck were studied. All patients had preoperative computed tomography or magnetic resonance imaging, and all patients had some form of radical neck dissection. The sensitivity of clinical exam was compared with the sensitivity of computed tomography or magnetic resonance imaging in ability to detect nodal disease. The sensitivity of clinical exam alone was 71.7%, while the sensitivity of computed tomography or magnetic resonance imaging was 91.1%. Based on physical exam alone, there would be a 39% rate of occult disease; if computed tomography or magnetic resonance imaging data is combined with physical exam, the occult disease rate would drop to 12%. All centers performing elective neck dissection must reassess their rationale or restudy their occult disease rate with computed tomography or magnetic resonance imaging.