The article presents a case study of a 21-year-old Polish female with a short history of an enlarging, painful, midline neck swelling and odynophagia. She underwent a transcervical excision of an epidermoid cyst, which was abutting her airway posteriorly, with nasal intubation and close observation in ICU. She has enjoyed full relief of her symptoms and an excellent cosmetic outcome. The article discusses the challenges of diagnosis and management of midline neck swellings. In particular, avoiding needle aspiration and management of the airway are highlighted.