To determine the optimal management of patients with penetrating wounds to zone II of the neck, we performed a prospective evaluation of 120 consecutive patients with such injuries, correlating the results of clinical and diagnostic examinations with operative findings. Seven patients presenting with life-threatening hemorrhage from the neck wound were operated on immediately; the remaining 113 patients underwent arteriography, laryngotracheoscopy, esophagoscopy, and esophagography, followed by neck exploration. Forty-eight major injuries were identified in 35 neck explorations. Five patients were identified with clinical and diagnostic findings that were considered normal preoperatively; however, at operation six major injuries were found in these patients. This study indicates that potentially lethal injuries to major vascular and visceral structures in the neck may go undetected if selective exploration criteria are used in the decision to explore penetrating wounds to zone II of the neck.