Thoracic outlet syndrome (TOS) is defined as the signs and symptoms caused by compression of brachial plexus and subclavian vessels in the cervicoaxillary region. Cervical ribs are very rare causes of TOS. Most of them are asymptomatic and incidentally diagnosed during routine chest x-ray. We presented here 4 cases of unusual cervical ribs articulating with hypertrophied scalene tubercle with different clinical presentations including: TOS, palpable mass at the supraclavicular region, and asymptomatic. TOS was treated surgically with good results. In conclusion, complete cervical costa, articulating with hypertrophied scalene tubercle is a very rare cause of TOS. Scalenotomy and complete resection of the cervical rib is a good choice for treatment. In addition, the cervical ribs should be considered in the differential diagnosis of the palpable masses seen at the supraclavicular regions. Plain radiographs are enough for diagnosis; however, 3-dimensional computerized tomography provides many advantages in preoperative surgical planning and demonstrating the articulating structure of the cervical ribs in a detailed manner.