Purpose To define the accuracy of fine‐needle aspiration cytology (FNAC) in diagnosing persistent or recurrent neck metastases in previously irradiated patients. Methods The study was performed according to the PRISMA‐DTA guidelines. Results A total of 382 FNACs were used for calculation of diagnostic accuracy parameters. The overall pooled sensitivity and specificity in detecting malignant nodes were 69.1% (95% CI: 56.3%‐80.7%; I2 = 79.5%) and 84.2% (95% CI: 71.8%‐93.5%; I2 = 87.0%), respectively. Cumulative diagnostic odds ratio (DOR) was 16.54 (95% CI: 4.89‐38.99; I2 = 65.8%), while cumulative positive and negative likelihood ratio (PLR and NLR) were 5.4 (95% CI: 2.3‐11.2) and 0.37 (95% CI: 0.22‐0.54), respectively. Conclusions FNAC alone could not guide the decision to perform a salvage neck dissection in previously irradiated patients, but its results should be assessed in relation to the specific clinical context.