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<h4>Objectives</h4>This study aims to propose a cytological classification, to evaluate predictive factors of the final malignancy, and to suggest a proper management strategy for neck lymph nodes (LNs) with indeterminate cytology.<h4>Methods</h4>Patients who had neck lymphadenopathy with indeterminate cytology between 2007 and 2017 were analyzed retrospectively in a tertiary medical center. Cytological classification was conducted according to the cytological descriptions. We examined the clinical characteristics according to the final diagnosis of the neck lymphadenopathy.<h4>Results</h4>According to the final diagnoses, there were 142 malignant and 95 benign neck LNs among 237 patients. Multivariate analyses using a stepwise logistic regression model showed that cytological classification [p < 0.001, OR = 5.67 (3.48-9.23)], prior history of malignancy [p = 0.01, OR = 2.97 (1.26-6.99)], long axis [p = 0.01, OR = 3.06 (1.33-7.06)], short-to-long axis (S/L) ratio [p = 0.047, OR = 2.15 (1.01-4.57)] and internal echogenicity [p = 0.01, OR = 2.72 (1.26-5.86)] were independent predictors of malignancy.<h4>Conclusions</h4>In patients who have neck LNs with indeterminate cytology, a cytological classification and four other predictors (prior history of malignancy, long axis ≥ 1.93 cm, S/L ratio ≥ 0.64 and heterogeneity of internal echogenicity) are statistically associated with the risk of malignancy and helpful in guiding further management.