OPEN ACCESS TEXTBOOK OF GENERAL SURGERY MINOR SURGICAL CONDITIONS OF CHILDHOOD AJW MILLAR RA BROWN STERNOMASTOID `TUMOUR' Management (FIBRO- MATOSIS COLLI) AND A combination of active and postural TORTICOLLIS physiotherapy is successful in the vast majority of cases. Active: the child's Clinical evidence head is taken gently through a full This may present in three different range of movement (chin to shoulder, ways depending upon the age of the ear to shoulder on each side and patient. extension/flexion.) Postural: · In the neonate 2 - 3 weeks old a positioning such that the child is firm swelling is noticed in the neck encouraged to turn the head towards which is localized to the the affected side e.g. cot position, car sternomastoid muscle. Usually seat, etc. Facial asymmetry cannot be detected because of torticollis - expected to correct itself after the age `wry neck'. Occasionally presents of 5 years. In those cases which with facial and cranial asymmetry. present late or where no progress is · In the older infant there may be no obtained, the muscle is surgically history of a swelling but the divided. In the older child the sternomastoid muscle is now firm investing deep cervical fascia on that and foreshortened. `Wry neck' side is also divided. Less than 5% of · The older child may present with all cases diagnosed in infancy require torticollis. The face is rotated away surgery. It is important to continue from the affected side and the with physiotherapy after surgery. head tilted towards the affected side. This is due to the shortening THYROGLOSSAL CYST AND and fibrosis in the muscle with FISTULA facial and cranial asymmetry are usually apparent. A common problem. Most appear before 5 years of age. Pathology The cause is unknown. However, it Clinical evidence: The cyst usually may well be present in utero thus lies in the midline below the hyoid causing obstetric problems. There is a bone. It is a discreet, firm cystic 20% incidence of abnormal structure. It may become inflamed presentation. Histological changes and subsequent discharge or drainage are the same at all ages; a typical will lead to a persistent fistula. The endomycial fibrosis around individual diagnosis is suggested when, with the muscle fibres which then undergo mouth opened thus fixing the platysma atrophy and fibrous replacement. The and mandible, the tongue is protruded effect of this is to shorten the and the cyst moves upwards. sternomastoid muscle, which over a period of time results in facial Embryology: At the 4th week the asymmetry and plagiocephaly. tongue develops from several growth buds in the floor of the primitive Other causes of torticollis should be pharynx. Just caudal to this is the excluded: localized pathology in the foramen caecum from which the neck which may be inflammatory or thyroid diverticulum develops. During neoplastic causing tilting of the head, the 7th week this diverticulum ophthalmologic conditions such as descends to the front of the neck and squints and nystagmus, and skeletal remains connected to the foramen abnormalities of the cervical spine. caecum by the thyroglossal duct. The branchial arches are developing at the anterior fontanelle. Dermoids over the same time, the ventral 2nd and 3rd eyebrow (external angular dermoid) arch cartilages forming the hyoid bone. very uncommonly have a deeper There is thus an intimate relationship extension. Those on the scalp also between the thyroglossal duct and the only rarely have a deep extension but hyoid bone. The cyst may be found may be mistaken for other pathology, anywhere from the thyroid to the base e.g. haemangiomas, hamartomas and of the tongue, the cyst arising from the lipomas. thyroglossal duct. Although the cyst is usually connected by a single Treatment: Excision. Pre-op x-ray primary duct structure there may be and ultrasound to exclude deep several small accessory ducts running extension. Dermal sinuses and parallel particularly above the hyoid posterior cysts nearly always have a bone. The duct is lined with stratified deep extension into the CNS, and squamous or ciliated columnar require pre-op CT scan. epithelium with associated mucus secretion. There may be an incidence BRANCHIAL FISTULAE, CYSTS of ectopic thyroid tissue, usually AND CARTILAGINOUS REMNANTS dysplastic, in relation to the duct or cyst. These occur in the head and neck and result from embryonic structures that The treatment is to remove the cyst or have failed to completely disappear sinus and the thyroglossal duct in its after their temporary foetal presence in entirety up to the base of the tongue. early embryonic life. To understand This will include the mid-third of the these lesions the embryology of the hyoid bone (Sistrunk's operation). If head and neck should be studied. only the cyst is removed morbidity is (See Chapter: The Anatomy of the significant with persistence of Abnormal, Part II. A synopsis of secretion local recurrence (30%) and Surgical Anatomy - Lee McGregor, DJ sinus formation. Recurrence is also du Plessis; or The Developing Human, attributed to failure of removal of Clinically Orientated Embryology - KL inferior extension of the tract; or in the Moore.). supra-hyoid area multiple fistulous tracts Sinuses or fistulae related to . second arch. These are the EPIDERMOID / DERMOID CYST commonest branchial remnants. Fistulae discharging mucus are These cystic structures occur in lines present from birth and are evident of fusion. Ectodermal elements along the anterior border of the become buried beneath the skin sternomastoid. There is a 15% surface leading to the formation of incidence of bilaterality. They may cysts. Sebaceous glands, hair follicles also occur in families. The lining of the and connective tissue may be present tract on the inner two-thirds is in the cyst wall giving rise to the typical columnar epithelium and the outer sebaceous material. There may be a one-third is squamous epithelium. The deeper penetration through underlying course of this tract can be predicted bone giving rise to a `dumb-bell' because it arises from the cervical configuration. These inclusion cysts sinus where the second branchial arch are differentiated from the so-called overgrows the third and fourth. The dermoids that occur in ovaries and track is related above to the IXth testes which are in fact teratomas. nerve, the stylopharyngeus muscle extending into the tonsillar fossa, and Common sites: Epidermoid cysts - more inferiorly it traverses the fork of midline supraclavicular area of the the carotid bifurcation, the XIIth nerve, neck and on the scalp over the internal jugular vein and goes beneath the posterior belly of digastric and HAEMANGIOMAS / VASCULAR stylohyoid to finally open on the skin MALFOR-MATIONS along the lower part of the anterior medial border of the sternomastoid. Although grouped under a single term, haemangiomas encompass a wide Sinuses or fistulae related to the range of pathology. Histological first arch are uncommon and classification is based on the size of classically present inferiorly as an the vascular structure in the lesion: opening on the skin below the ramus capillary, mixed, cavernous, A-V of the mandible, with a tract extending fistulae. Clinically they can be divided upwards to the junction of the bony into two groups. Haemangiomas and and cartilaginous part of the external malformations. auditory canal. The track is intimately related to the facial nerve, the Haemangiomas usually occur in branches of which may have a females, are visible at birth in only variable relationship to the sinus tract. ±40%, but subsequently undergo tremendous endothelial proliferation Pre-auricular sinuses are probably with rapid increase in size. Histology ectodermal inclusions related to the is mainly capillary. This group can be development of the auricle, which expected to subsequently involute. forms from 6 cartilaginous tubercles. The commonest of this variety is Cartilaginous remnants usually arise termed a strawberry haemangioma along the anterior border of the (capillary histology). Treatment is sternomastoid and extend into the thus expectant and involution should fascia of the muscle. These also be complete by about 5 years of age. commonly have a family history and In those areas where the lesion is are bilateral. Surgery is only advised if constantly traumatized, causing symptomatic. infection and bleeding, e.g. the scalp and perineal area, or where its site Branchial cysts tend to present in affects vital functions e.g. over the eye later childhood or early adult life and where complete closure may rapidly are again related to the anterior border result in amblyopia, excision may be of sternomastoid, usually lying deep to attempted. the muscle. They are typically described as feeling like a "half-filled The stork bite or neonatal staining hot-water bottle" with a thick wall and may appear shortly after birth and is contain a yellow creamy substance classically related either to the nape of with cholesterol crystals. They are the neck, over the forehead or sacrum. usually unilateral. Branchial cysts It can be expected to spontaneously related to the first arch may occur fade over several months. within the parotid gland - often misdiagnosed as a pleomorphic The second group can be termed adenoma. malformations in that the lesions are present to their total extent at birth and will not fade but will grow at the same Treatment of all these is careful rate as the child. These show normal excision, being aware of the related endothelial mitotic activity. The port structures. Surgery of branchial wine stain consists of a malformation fistula is usually conducted before the located within the dermis - third year of life as the neck is shorter histologically it is a capillary vascular and the whole fistulous track can be malformation. These lesions removed through a single incision. In correspond to the skin distribution of the older child two separate "step various sensory nerve branches, e.g.