Head and neck lesions are commonly encountered in the pediatric population. There are three basic classifications of lesions—congenital, inflammatory, and neoplastic. Congenital lesions are common and may include cystic hygromas; hemangiomas; branchial cleft anomalies; preauricular pits, sinuses, and cysts; thyroglossal duct cysts; dermoid and epidermoid cysts; and others. It is important for the pediatrician and pediatric surgeon alike to be familiar with the embryologic origin and differentiation of the head and neck structures in order to accurately diagnose, triage, and treat these lesions. Inflammatory lesions are also common in pediatric patients and usually involve the lymph nodes. However, it is not unusual for secondarily infected congenital lesions to mimic inflammatory lesions. Fortunately, in contrast to adults, most head and neck lesions in children are benign. Malignant lesions, including lymphoma, thyroid carcinoma, rhabdomyosarcoma, and neuroblastoma, are occasionally encountered. A high degree of suspicion is important in distinguishing benign from malignant lesions. Early biopsy is essential if there is any question of malignancy. A careful history and physical examination will often establish the diagnosis. The presence of a painless mass present since birth or identified shortly after birth is consistent with a lesion of congenital origin. Acute or subacute enlargement, tenderness, and overlying erythema or fluctuance of the cervical lymph nodes, especially if temporally related to a recent upper respiratory tract infection, suggest an inflammatory origin. Cervical lymphadenopathy without signs of inflammation may be reactive, but malignancy needs to be excluded. Malignant lesions tend to be painless, solid, and associated with other systemic manifestations. Additional measures may be necessary under certain circumstances to establish the diagnosis and guide further therapy. Ultrasonography may be useful in determining the cystic or solid nature of a mass. Computed tomography (CT) imaging may provide information regarding the extent of the lesion and involvement of vital structures. Needle aspiration may identify the presence of infection or malignant cells, but excisional or incisional biopsy is usually required to establish a definitive diagnosis.