Management policies for penetrating wounds of the neck vary from mandatory surgical exploration to selective surgical exploration following extensive or minimal imaging investigation. In order to review the treatment protocol at Sheba Medical Center, Tel Hashomer, Israel, we retrospectively studied 21 patients who were treated between the years 1984 and 1989. Thirteen had gunshot injuries and eight had stab wounds. Eight patients had undergone immediate exploration of the neck. Four patients had died, but all of these latter patients had evidence for significant bleeding that could have been detected within a short time of admission. On the basis of our findings and previous studies, we conclude that: presenting features of neck injuries should be differentiated into two basic categories: immediately life-threatening and not immediately life-threatening. Immediately life-threatening features include overt massive bleeding, expanding hematoma, non-expanding hematoma in the presence of hemodynamic instability, hemomediastinum, hemothorax, and hypovolemic shock. In all of these cases, immediate surgical exploration is mandatory. Non-life-threatening features include any signs of vascular complication in a hemodynamically stable patient, signs of upper aerodigestive tract lesions (when initial treatment has already relieved respiratory distress) and peripheral neurological deficits. These patients should undergo thorough imaging investigations on the basis of which the need for and the nature of possible surgical intervention can be determined.