Paediatrics: Miscellaneous conditions

Miscellaneous conditions

Tongue-tie

Common and rarely causes symptoms. Tongue-tie does not cause lisp, and is most definitely not responsible for eating problems in an older child. Division of a tongue-tie does not alter the natural history of either con-dition. Tongue-tie does affect the ability of newborns to breastfeed and division of the lingual frenulum within the first week of life will correct this problem. Bottle feeding is not affected.

Dermoid cysts

Common in children (Fig. 23.22). Dermoids are non-tender, mobile subcu-taneous cysts filled with keratin, hair follicles, and sebaceous glands. They enlarge slowly and should be treated by excision. Dermoid cysts occur most frequently along lines of embryological fusion, such as lateral corner of the eyebrows (external angular dermoid), midline of the neck, over the bridge of the nose, and suprasternal notch.

Thyroglossal duct cysts (TDC)

Present with midline swelling in the neck, just below the hyoid bone. The swelling rises with tongue protrusion and swallowing. TDCs develop from epithelial remnants left after descent of the developing thyroid from the foramen caecum at the base of the tongue. TDCs gradually enlarge and eventually become infected, which makes excision more difficult. Treatment is surgical removal of the central portion of the hyoid bone along with the cyst and track.

Branchial remnants

Branchial remnants persist from the branchial clefts during embryogenesis of the head and neck. Anomalies of the second branchial cleft are by far the most common. They can be a cyst, a sinus tract, or rarely a fistula.

•   Branchial sinuses: present as small cutaneous openings along the anterior lower third border of the sternocleidomastoid muscle that discharge mucus (Fig. 23.23). They can communicate with the tonsillar fossa (branchial fistula). Management is excision to prevent infection.

•   Branchial cysts: uncommon neck swellings along the anterior border of the sternomastoid. The differential includes cystic hygroma, which is more common, and the treatment is surgery.

Cystic hygroma (CH)

A congenital malformation of the lymphatic system. CHs present in early childhood as soft multilocular cystic swellings that often appear after an intercurrent viral infection. CHs are more often found in the neck and axillae, although they can occur anywhere, including inside the abdomen or thorax. Large cervical cystic hygromas may present at birth with air-way obstruction. Small CHs require no treatment. Large lesions infiltrate the surrounding tissues making complete surgical excision impossible. Intralesional injection of OK432 (lyophilized product of Streptococcus pyo-genes) is an alternative to surgery in some cases.

Congenital torticollis

Within the first weeks of birth a small swelling in the baby’s neck is noticed. A sternomastoid tumour is a palpable area of fibro-sis in the lower sternomastoid muscle (SM) and is a transient phenome-non that will resolve after a few months. Sometimes there is a history of dystocia. Shortening of the SM results in torticollis with rotation and tilting of the head to the opposite side. Management is conservative in most cases with passive exercises to achieve full neck movements. Hemifacial atrophy and strabismus may develop unless full movement is restored. Occasionally it is necessary to divide the SM, but this is no substitute for physiotherapy.