Branchial cleft cysts usually present as a soft cystic mass along the anterior border of the sternocleidomastoid muscle. These lesions are usually recognized in the second or third decade of the patient’s life when they suddenly swell or become infected. To prevent recurrent infection and possible carcinoma, they should be completely excised with their fistulous tracts. First branchial cleft cysts present high in the neck, sometimes just below the ear. A fistulous connection with the floor of the external auditory canal may be present. Second branchial cleft cysts, which are more common, may communicate with the tonsillar fossa. Finally, third branchial cleft cysts, which may communicate with the piriform sinus, are also rare and present low in the neck.