To determine trends in management, twenty-two years' experience with penetrating wounds of the cervical esophagus in thirty-nine patients has been evaluated. There were three deaths, all as a result of delayed operative repair. Experience gained from the earlier years of this study led to a marked reduction in mortality in the later years as a result of an increased index of clinical suspicion, coupled with an aggressive operative approach with primary closure and adequate drainage. A nonoperative approach has been suggested by others for small esophageal perforations after endoscopy and perforation from foreign objects. For penetrating injuries of the esophagus, operation and definitive repair is mandatory.