Congenital torticollis (Torticollis)
Torticollis is a congenital and persistently fixed head tilt accompanied by its rotation to the opposite side. The patient assumes a characteristic forced position.
Main causes:
- Structural shortening of the sternocleidomastoid muscle (m. sternocleidomastoideus).
- Congenital anomalies of the cervical vertebrae.
To establish a precise diagnosis, in addition to visual inspection and recording the typical head position, cervical spine radiography is mandatory. This study is necessary to exclude concomitant bone pathology and clarify the etiology of the process.
Treatment tactics:
- Conservative therapy: used at an early age for mild pathology. It consists of special fixation of the head with a tilt toward the healthy (opposite) side.
- Surgical intervention: indicated in severe cases or when conservative methods are ineffective. The optimal age for surgery is 2–3 years. The surgeon performs transection or artificial lengthening of the m. sternocleidomastoideus tendon.
Supernumerary cervical ribs
The presence of supernumerary cervical ribs leads to visual shortening and pronounced deformation of the neck contours, as well as a change in the patient's habitual head position.
The main clinical danger of this pathology is the potential compression of major vessels and nerve trunks passing through this anatomical region.
The diagnosis is confirmed using standard X-ray imaging. If the anomaly causes impaired motor functions of the neck or compression of vital organs, exclusively surgical treatment is indicated—resection (removal) of the additional bone structures.
Median cysts and fistulae of the neck
Midline neck masses form due to disruptions in the embryological development of the thyroid gland isthmus. They represent remnants of the thyroglossal duct (ductus thyreoglossus).
Characteristics of the thyroglossal cyst:
- Localized strictly along the midline of the neck, in the projection of the hyoid bone.
- On palpation, it is defined as a dense, elastic, rounded, and completely painless mass.
- The cyst is tightly fused with the skin and underlying tissues.
- Pathognomonic sign: during swallowing, the mass actively moves up and down along with the hyoid bone.
Upon suppuration and subsequent rupture of the cyst, a midline fistula is formed. It is palpated as a dense connective tissue cord directed strictly along the midline upward toward the hyoid bone. Seropurulent exudate constantly discharges from the fistulous tract.
Probing (the probe passes freely up to the hyoid bone) and fistulography are used to diagnose fistulas, which helps to accurately determine the direction and total length of the tract. Treatment is strictly surgical—complete radical excision.
Surgical technique for thyroglossal cyst excision
Surgical removal of a thyroglossal cyst requires particular radicality to prevent possible recurrence. This is due to the fact that the rudimentary duct passes directly through the body of the hyoid bone or lies closely adjacent to it.
Main stages of the surgery:
- Meticulous dissection of the cystic mass down to the hyoid bone.
- Radical resection of the hyoid bone on both sides of the adjacent cyst.
- Removal of the cyst as a single, intact block along with the resected middle part of the hyoid bone.
Lateral cervical cysts and fistulae
Unlike median cysts, lateral neck masses represent embryonic remnants of the thyroglossal duct.
Anomatomically, they are located on the lateral surface of the neck: between the larynx and the inner surface of the sternocleidomastoid muscle (m. sternocleidomastoideus). The fistulous tract or the upper pole of the cyst always courses steeply upward toward the pharynx.
The gold standard for diagnosing lateral fistulae is fistulography, which allows detailed visualization of the spatial position, true dimensions, and direction of the abnormal tract. Treatment consists of complete surgical excision of the pathological tissues.
Briefly: answers to topical questions
Specifically, which major vessels and nerve trunks are compressed in cervical rib syndrome?
In cervical rib syndrome, the brachial plexus and the subclavian artery are subject to compression.
- Brachial plexus (plexus brachialis) — compressed in the space between the anterior scalene muscle, the cervical rib (or its fibrous band), and the first rib.
- Subclavian artery (a. subclavia) — compressed in the same location, along with its accompanying sympathetic fibers.
Compression of the plexus manifests as muscular weakness resembling Klumpke paralysis, while compression of the sympathetic fibers running along the artery causes vasomotor disturbances.
What conditions require differential diagnosis with a lateral neck cyst?
Lateral neck cysts are differentiated from chronic lymphadenitis, dermoid cysts, soft tissue tumors, and metastases of malignant neoplasms.
- Chronic lymphadenitis — specific and non-specific forms.
- Dermoid (epidermoid) cysts.
- Tumors and tumor-like lesions of the soft tissues of the neck, vessels, nerves, and thyroid gland.
- Metastases of malignant tumors.
To avoid confusing cysts: Median — in the Middle, Moves with the thyroid duct. Lateral — on the Side, hides behind m. sternocleidomastoideus and extends to the pharynx.
Class and exam questions
Radiography of the cervical spine is necessary to rule out bone pathology (cervical spine developmental anomalies) which may be the primary cause of fixed head tilt.
Radiography of the cervical spine is necessary to rule out bone pathology (cervical spine developmental anomalies) which may be the primary cause of fixed head tilt.
How to clinically differentiate a thyroglossal duct cyst from lymphadenitis?
The median cyst is painless, located strictly in the center, and has a characteristic sign — it moves along with the hyoid bone during swallowing because it is fused to it.
Why is a part of the hyoid bone removed during the excision of a thyroglossal duct cyst?
The thyroglossal duct, from which the cyst forms, passes through or directly adjacent to the hyoid bone. If the middle part of the bone is not removed en bloc with the cyst, the risk of recurrence is high.
What else to study on this topic
- Radiological signs of cervical spine anomalies
- Technique of neck fistulography
- Technique of conservative fixation in infant torticollis
- Topographic anatomy of the m. sternocleidomastoideus
- Embryogenesis of the thyroid and thyroglossal ducts
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