Lesions of the face and neck

Congenital neck masses

Congenital neck masses may include thyroglossal duct cysts, dermoid cysts, lymphangiomas, branchial cleft cysts, teratomas or congenital muscular torticollis.

Thyroglossal duct cysts

During embryologic development, the thyroid gland starts out as a group of cells that are located at the base of the tongue in the back of the mouth. As the embryo grows, the thyroid cells move down a canal, called the thyroglossal duct, to the final location of the thyroid in the neck. Once the thyroid reaches its final location, the duct involutes, or disappears. If the duct does not fully disappear, portions of the duct can create pockets, called thyroglossal duct cysts. These pockets can fill with fluid or mucus.

Thyroglossal duct cysts are typically removed surgically. However, if the cyst is infected, a course of antibiotics is usually required before the cyst can be removed. Removing an infected cyst without adequately treating the infection increases the risk of complication and recurrence of the cyst.

Dermoid cysts

A dermoid cyst is a pocket or cavity under the skin that contains tissues normally present in the outer layers of the skin. The pocket forms a mass that is sometimes visible at birth or in early infancy but often is not seen until later years.

Dermoid cysts are usually found on the head or neck, and sometimes on the face, commonly in or near the eyebrow.

Dermoid cysts tend to enlarge slowly over time therefore specific treatment will be determined by the physician. Treatment frequently includes surgery to remove the cyst when it is first detected. Aspirating the cyst with a needle, or lancing/draining it is not an option because the cyst lining needs to be removed in order for it to not grow back.

Branchial cleft cysts

Branchial Cleft Cysts are epithelial (skin) lined cavities filled with mucous that form a mass along the side of the neck. These are congenital (abnormality during fetal development) cysts, resulting from a failure of gill-like embryonic structures (branchial arches) to disappear during maturation of the fetus, as they normally should. This results in a persistent pouch, which later can fill with fluid. Although the cyst is present at birth, it may not present until years later.

Elective surgical removal is the treatment of choice. If there is an abscess, emergency incision and drainage is necessary. The goal, however, is to remove the cyst prior to infectious complications. Your doctor may order a CT scan or an MRI to aid in diagnosis and surgical planning.

Teratoma

Teratomas (from Greek terato meaning “a monster” and onkoma meaning “swelling or mass”) and other germ cell tumors are relatively common solid neoplasms in children. They may occur in both gonadal and extragonadal locations. Locations and specific tumor types depend on the age of the child. The tumors are grouped together because they all appear to arise from postmeiotic germ cells. Most of the malignant tumors produce markers that can be serologically assessed.

In general, total resection of tumor is the goal. The tumor and involved adjacent structures should be resected en bloc, if this is possible and does not lead to disfigurement.

Muscular torticollis

Congenital muscular torticollis, also called twisted neck or wryneck, is a condition in which an infant holds his or her head tilted to one side and has difficulty turning the head.

In congenital torticollis, the muscle that extends down the side of the neck – the sternocleidomastoid muscle — is tight and shortened. Often, a small lump will be noted along the muscle. For most babies, stretching exercises and simple changes in how the infant is held or positioned will gradually lengthen the muscle and correct the problem.

Congenital muscular torticollis is present at birth or develops soon after. It is usually discovered in the first 6 to 8 weeks of life, when a newborn begins to gain more control over the head and neck.

Nonsurgical Treatment

The standard treatment for congenital muscular torticollis consists of an exercise program to stretch the sternocleidomastoid muscle.

Stretching exercises include turning the baby’s neck side to side so that the chin touches each shoulder, and gently tilting the head to bring the ear on the unaffected side down to the shoulder.

These exercises must be done several times a day. Your doctor or a physical therapist will teach you how to perform the exercises.

There are other options that can help. Position toys where your baby has to turn his or her head to see them. Carry your child so that he or she looks away from the limited side. Position the crib so that your child must look away from the limited side to see you outside the crib.

Surgical Treatment

If nonsurgical options do not correct the torticollis, your doctor may suggest surgery.

Approximately 10% of children with congenital muscular torticollis require surgery. The operation is typically scheduled once the child reaches preschool years. The procedure will lengthen the short sternocleidomastoid muscle, and may be done as an outpatient surgery, meaning your child could go home the same day.

Vascular birthmarks

Vascular birthmarks include hemangiomas and vascular malformations.

Hemangiomas

An infantile hemangioma (hem-an-gee-o-ma), sometimes called a strawberry mark, is a very common type of birthmark made of blood vessels. Most hemangiomas are not visible at birth, but appear during the first weeks of life. When they do appear, they may be mistaken for a small bruise, scratch or tiny red bump. All skin hemangiomas will be visible by six months of age. They may occur anywhere on the skin surface, but they are most common on the scalp, face and neck. Some patients have deep lesions, that do not involve the skin, but present as an expanding lump under the skin. Unlike other types of birthmarks, they will grow and change quickly during your child’s first few months. They follow a fairly predictable course, and most will start to shrink after the first birthday. The large majority of these birthmarks disappear on their own by age five. Hemangiomas that grow rapidly, bleed, ulcerate (have breakdown of the overlying skin), or create a functional problem (most commonly visual) may require treatement. Medical and surgical treatments are available. The most commonly used medical therapy is propranolol, a common medication that is also used to help patients with high blood pressure. Surgical treatments include excision (removing part or the entire lesion) or laser therapy. A pulsed dye laser therapy is used most commonly. Its wave length allows the laser to treat the red, abnormal tissue of the hemangioma while sparing the surrounding normal tissue.

Vascular Malformations

Unlike hemangiomas, which most often resolve on their own, vascular malformations tend to be lifelong problems.

Lymphangiomas

Lymphangiomas are uncommon congenital malformations of the lymphatic system that involve the skin and subcutaneous tissues. Because they involve the lymph vessels they are considered a type of vascular birth mark. Classification of lymphangiomas is typically devided into 2 major groups. The more superficial vesicles are called lymphangioma circumscriptum and the more deep-seated group is includes cystic hygromas and cavernous lympangiomas. For treatment purposes they are often classified as macrocystic and microcystic, as the size and number of the cysts in a lymphangioma may guide what treatment option to pursue.

These lesions are very difficult to treat and they may be prone to recurrent infection. Antibiotic therapy, oral or intravenous, or incision and drainage may be required to treat infected lymphatic malformations. Definitive or “curative” therapy is often not possible. They tend to invade adjacent normal structures, making complete excision impossible. Macrocystic lesions may respond to sclerotherapy. This involves injecting a caustic agent into the lesion to induce scarring, closing the cysts and shrinking the lesion. Steroid and radiation therapy have proven ineffective. However, propranolol represents a potential new option, which may be of benefit even for intractable diffuse lymphangiomatoisis.

Portwine Stains

These are common vascular malformations involving the smallest blood vessels called capillaries. The post capillary venules are also involved. Because they tend to involve large areas of the skin, surgical excision is usually not appropriate. Pulsed dye laser therapy can help improve the appearance of these lesions. Because they are malformations, they do not resolve and are present for the patient’s entire life. Many patients elect to have pulsed dye laser therapy once a year or so to help lighten the color of the lesion.

Venous Malformation

Venous malformations are collections of abnormal veins. They give the overlying skin a blue color. They are typically asymptomatic, but can form phleboliths which can be painful. Surgical excision is an option, but is not always curative.

Arterovenous Malformation

This lesion involves an abnormal connection between a thin walled venous structures and muscular arterial structures. Because this type of malformation exposes the thin walled veins to an arterial pressure head, they require more aggressive treatment to avoid life threatening bleeding. Treatment options include embolization and excision.