Penetrating injuries of the neck are considered difficult to assess and manage. This small body area contains a dense concentration of vital vascular, aerodigestive, and nervous system structures. Many of these structures are not accessible to physical examination, and the surgical exposure of some of them is a technical challenge. The initial aggressive operative management of earlier years has been largely replaced by a selective conservative approach, but a major controversy still exists. The role of physical examination and various diagnostic procedures in the initial assessment of penetrating neck injury has become the theme of hundreds of publications. The surgical techniques for the management of specific injuries are still much debated and need resolution. This article discusses some of the complex problems related to the initial evaluation of penetrating neck injuries, offers guidelines in the management of specific difficult injuries, and highlights the controversial areas where more research is still needed.