The management of anterior penetrating neck injuries remains highly controversial. This is a review of our treatment of such injuries over the preceding decade. During the first 6 years all injuries were explored. Of 75 patients explored, only 33 (44%) had significant injuries. During the last 4 years, patients were managed selectively. Patients with bleeding, crepitation, dysphagia, compromised airways, or for whom full clinical evaluation was not possible underwent prompt formal operative exploration. All other patients were observed. Of 48 patients who underwent explorations, 41 (85%) had significant injuries. Thirty-six patients were observed with no adverse sequelae. Ancillary diagnostic testing was only routinely done in level I injuries. Over the last 10 years we evolved from mandatory exploration to selective exploration of anterior penetrating neck injuries. Our experience confirms the safety and cost-effectiveness of a selective exploration policy. Furthermore, observation does not mandate extensive ancillary diagnostic testing for level II and level III injuries.