Management of penetrating wounds to the neck remains controversial despite decades of discussion in the literature. We assessed 393 consecutive stab wounds penetrating the platysma operated at our trauma service between January 14, 1991 and September 30, 1992 to evaluate our policy of mandatory neck exploration (NE). Injury to the common (n = 19 cases), external (n = 7), internal carotid (n = 5), innominate (n = 2), subclavian (n = 20), vertebral (n = 12), facial (n = 2), and intercostal (n = 2) arteries; the external (n = 36), internal (n = 65), subclavian (n = 20), and innominate (n = 4) veins; the pharynx/esophagus (n = 21); and the trachea (n = 28) was considered a positive NE (n = 167). 226 NEs were negative. Except for hemiparesis and bruit, the presence of clinical signs (shock, active hemorrhage, hematoma, surgical emphysema, dysphagia, blowing wound) did not predict a positive NE. Clinical signs were absent in 30% of positive NEs and in 58% of negative NEs. Complications of positive NE included wound infection (n = 7 cases), chyle drainage (n = 6), cerebellar stroke (n = 1), pneumonitis (n = 8), reoperation for recurrent hemorrhage (n = 1), subclavian artery graft occlusion (n = 1), bronchopleural fistula (n = 1), and cerebrospinal fluid leak (n = 1). Negative NEs were complicated by a wound infection in four cases and pneumonitis in one case. The mean hospital stay was 4.3 days for those with a positive NE and 1.5 days for those with a negative NE.(ABSTRACT TRUNCATED AT 250 WORDS)