Painless Neck Masses Thyroglossal Duct Cyst = most common congenital midline mass ==> Concern that it may be ectopic thyroid tissue ==> Painless ==> Elevates with the tongue during swallowing (It is attached to the base of the tongue) ==> Requires ultrasound. Thyroid Scan if thyroid is abnormal. ==> Tx; Sistrunk procedure excsion of cyst and and mid-portion of the hyoid bone (not removing the portion of the hyoid leads to high rate of recurrence). Second Branchial Cleft Cyst = Most common branchial anomaly (90%) ==> Painless fluctuant mass in the anterior triangle ==> Arise due to failure of the embryonic branchial cleft to obliterate. ==> Ultrasound or CT may be useful to define mass and for pre-operative evaluation. Both are mostly asymptomatic, but may cause symptoms due to compression of local structures. Both may become infected secondarily, at which time they will no longer be painless. Treat with Abx if infected. Surgical excision should be delayed until active infection is resolved.