Aims In oropharyngeal squamous cell carcinoma (OPSCC), the management of the clinically node-negative (cN0) contralateral neck remains a topic of debate. The aim of the study was to risk-stratify OPSCC patients with cN0 contralateral neck involvement, assessing the need for ipsilateral versus bilateral neck treatment at a tertiary cancer referral centre. Methodology This was a retrospective review of 329 consecutive OPSCC patients with cN0 contralateral neck who received curative-intent treatment at our institution between January 2003 and December 2023. Based on institutional protocol, all base of tongue (BOT) tumours, and tumours from other oropharyngeal subsites within 1 cm of midline, were treated with bilateral neck treatment, regardless of nodal status. The primary endpoint was contralateral neck recurrence (CNR). Data was collected on demographics, tumour staging, treatment protocols, and outcomes. Five-year overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Results The median follow-up time was 43 months (range: 1-148 months). The cohort included 61.4% tonsil and 33.4% BOT primaries. Six patients (1.8%) developed CNR, all with tonsil primaries, five of whom had HPV-positive tumours. No BOT primary patients experienced CNR. Of the 232 patients who received bilateral neck treatment, three (1.3%) experienced CNR, compared to three (3.3%) of the 90 patients who received ipsilateral neck treatment. There was no statistically significant difference in 5-year OS (94.4% for bilateral vs. 89.2% for ipsilateral treatment, p=0.262) or DFS (92.2% vs. 83.2%, p=0.068) between the two groups. Conclusion Our findings support the current protocol of bilateral neck treatment for primary tumours in oropharyngeal subsites (other than BOT) located within 1 cm of midline. This approach may also be applicable to BOT tumours, however further studies are needed to confirm its efficacy in this subset of patients.