Objectives The objectives of this study are to describe the incidence and age range of presentation of lateral neck cysts, to evaluate a management algorithm for adults presenting with lateral neck cystic lesions and to report the age incidence at which malignant cystic lesions in the neck have clinically presented as lateral neck cysts. Design A retrospective review of histologically diagnosed branchial cysts between 1995 and 2014 at a single centre. Setting Oxford University Hospitals NHS Foundation Trust. Participants A single senior head and neck pathologist and the ENT head and neck team. Main outcome measures Does a dedicated pathway help to identify malignancy in lateral neck cysts earlier in the diagnostic pathway? Results When using a random investigative pathway the sensitivity in distinguishing malignant from non-malignant was 93%, specificity 12% with a PPV of 83% and NPV 28%. When using a defined investigative protocol, the sensitivity was 94%, specificity 67%, PPV of 85% and NPV 86%. Conclusions This study conveys that using a structed pathway when working up patients with a lateral neck cyst results in a greater sensitivity, specificity, PPV and NPV in distinguishing malignancy compared to an unstructured workup. Key points 1) Establishing a lateral neck cyst as a benign structure is a diagnosis of exclusion 2) There is no established protocol for this pathway. 3) The need for a diagnostic pathway is important given the impact of COVID-19 4) The diagnostic challenge is differentiating benign from malignant 5) For lateral neck cysts a cut off age of 35 may not be appropriate