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Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis 251
Table 38.2: Ultrasound prediction of outcome of congenital muscular torticollis. 1. late diagnosis, after 12 months of age; and
Type I, 15% Fibrotic mass Spontaneous resolution 2. failure after at least 6 months of PSE with a significant head tilt,
Type II, 77% Diffuse fibrosis mixing with Spontaneous resolution persistent deficit of passive neck rotation, and a tight band in the
normal muscle sternomastoid muscle, often with hemifacial hypoplasia.
Type III, 5% Without normal muscle in the Surgical intervention There is evidence that surgical release of the sternomastoid
involved muscle contracture between 12 and 18 months of age maximises spontaneous
Type IV, 3% Fibrotic cord in the involved Surgical intervention (odds correction of plagiocephaly. Surgical correction also results in adequate
muscle ratio = 31.54, p = .0196) mobility and acceptable cosmetics in more than 90% of cases, with
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Source: Adapted from Hsu TC et al. Correlation of clinical and ultrasonographic features of some benefit even in older children. Other authors recommend
congenital muscular torticolis. Arch Phys Med Rehabil 1999; 80:637–641. delaying operative treatment until after 5 years of age, when the patient
can comply with postoperative bracing and physiotherapy. 19
Operative Procedure—Open Technique
1. The patient is placed under general anaesthesia with endotracheal
intubation or the use of a laryngeal mask airway. Anaesthetic
intubation difficulty may arise from abnormal tilt in the trachea, so a
prior cervical x-ray will guide the anaesthetist. Where available, fibre-
optic guided endotracheal intubation is the best.
2. The patient is positioned supine with the shoulder raised and neck
rotated to the contralateral side.
3. A 3–4cm transverse skin incision is made 1 cm above the sternal and
Figure 38.9: Residual left sternomastoid swelling in a five-month-old infant at 8 clavicular origin of the sternomastoid muscle.
weeks of physiotherapy. The tumour progressively reduced over 4 months.
4. The platysma is carefully divided along the line of incision to avoid
injury to the external jugular vein and accessory nerve.
5. The two heads of the sternomastoid muscle are dissected free
from the anterior and posterior layers of the investing fascia and are
subsequently divided using diathermy to prevent bleeding; some
advocate excision of a 1-cm segment of the muscle.
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6. Tight deep cervical fascia should be released, testing lateral and
rotational movement carefully under anaesthetic.
7. In severe cases of contracture, division of the upper end of the
sternomastoid may be necessary.
8. The platysma is then sutured with 4-0 interrupted absorbable suture,
and the skin is closed with 5-0 absorbable suture. There is no need for
Figure 38.10: A woman backing an infant with the head turned to the ipsilateral a drain provided haemostasis is well secured.
side of the sternomastoid tumour. Postoperatively, physiotherapy is resumed after wound healing to
maintain a full range of motion; some authors recommend using a neck
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brace for several months.
Alternative surgical approaches that have been described are a
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sternomastoid lengthening technique using a Z-plasty, and endoscopic
tenotomy of the sternomastoid contracture.
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Postoperative Complications
1. A hematoma usually will resolve, but sometimes requires aspiration
or drainage.
2. Residual contracture from incomplete division of both heads of
sternomastoid or cervical fascia over the posterior triangle of the neck
would need a reoperation.
3. Recurrent CMT is rare.
Figure 38.11: The baby’s mother does PSE assisted by a friend, while the The cosmetic appearance may be disfiguring, especially in the
surgeon watches. older child with severe contracture. This is usually due to anomalous
reattachment of the clavicular head of sternomastoid or loss of the
sternomastoid column of the neck.
have included placing toys and desirable objects on the ipsilateral side
of the lesion so that the child turns towards it. The child could also be Prognosis and Outcome
put to sleep with the head facing the ipsilateral side. Helmet treatment The prognosis for sternomastoid tumour is generally excellent if treated
has been described in some children with severe plagiocephaly, but it early. The child is able to achieve full range of head movement, and
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is usually impractical. the swelling resolves within 6 months. The majority of those who have
Operative Treatment surgery also do well.
Follow-up should continue until the sternomastoid muscle resolves
Surgical treatment is required in only about 5% of patients seen early, and feels normal, and full neck rotation is achieved. Older children
but is necessary in half of those presenting after 6 months of age. The should be monitored for development of scoliosis.
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indications for surgery are: