Case Presentation: Cervical-Facial Cystic Hygroma

No.  2

Pictures

Case Presentation (Cervico-Facial Cystic Hygroma)

History

A 3-year-old patient was referred to our OTO-HNS

Clinic due to a left sided neck mass noted

approximately 12 months prior to be seen in

our service. The patient was otherwise asymptomatic.

Physical

Examination

Soft non-tender neck mass localized on the left side in the lower aspect of the parotid area to the upper aspect of the neck at the level of the upper jugular-digastric area.

CT scan with

contrast

Axial CT image of the neck after contrast material enhancement.

The entire CT axial and coronal cut series (not shown here) revealed a mass in the above-described location.

(CT-1  Click here to enlarge the picture)

Procedure

(1)

(1)

“S” type on skin incision usually used in the parotid surgery localized in the area of the lesion.

(Surg-1  Click here to enlarge the picture)

(2)

(2)

Anterior facial flap elevation done. Silk traction sutures used for wide exposure of the surgical area.

(Surg-2  Click here to enlarge the picture)

(3)

(3)

The silk traction sutures as shown in the picture, are very useful in flap retraction with minimal trauma to the tissue. 

(Surg-3  Click here to enlarge the picture)

(4)

(4)

The facial nerve is exposed in its exit through the mastoid. The facial nerve bifurcation is clearly seen in the enlarged picture.  The superior division is seen in its normal pathway through the parotid gland. The inferior division of the nerve is exposed through surgical dissection and the mass, which was localized above, is retracted inferiorly with surgical clamps.

The sternocleiodomastoid muscle is seen exposed inferiorly.

(Surg-4  Click here to enlarge the picture)

(5)

(5)

This photography is one step further in the dissection compared to the previous picture but basically the same description is valid.

(Surg-5 Click here to enlarge the picture)

(6)

(6)

The surgical area after the specimen was removed.  Silk fracture sutures are still in place as described initially. Main trunk of the facial nerve with the superior division undersexed and the inferior division dissected. The sternocleidomastoid muscle is displaced with an Allis retractor. The posterior belly of the digastric muscle is seen just anteriorly attaching to the mastoid tip.

(Surg-6  Click here to enlarge the picture)

(7)

(7)

The sternocleidomastoid muscle was further retracted laterally to expose the accessory nerve not clearly seen in the previous picture.

In summary, the excision involved the exposure of the inferior division of the left facial nerve as well as a neck dissection of the zone II of the neck (Corner bound by the posterior belly of the digastric and the sternocleidomastoid muscles).

(Surg-7 Click here to enlarge the picture)

Pathology

Cystic hygroma

References for further reading:

1) Clary R. A., Lusk R. P.:Neck Masses, Chapter 95 in Pediatric Otolaryngology, (Bluestone, Stool, Kenna, editors),Volume Two, Third Edition, Saunders, pp. 1488-1496, 1996

2) Rood S.R., Johnson J. T.,Lipman S.P., Myers E.N.: Diagnosis and Management of Congenital Head and Neck Masses, A

Self-Instructional Package from the Committee on Continuing Education in Otolaryngology, American Academy of

Otolaryngology-Head and Neck Surgery Foundation, Inc., 1988

3) Cunningham M.: Salivary Gland Surgery, Chapter 23 in Surgical Atlas of Pediatric Otolaryngology (Bluestone C.D., Rosenfeld R. M., editors),  B.C. Decker, pp. 515-539, 2002.

4) Richardson M.A., Rosenfeld R.M.: Congenital Malformations of the head and neck, Chapter 22 in Surgical Atlas of Pediatric Otolaryngology (Bluestone C.D., Rosenfeld R. M., editors),  B.C. Decker, pp. 496-498, 2002.

5) Surgical Pediatric Otolaryngology: Potsic W. P., Cotton R. T., Handler S.D., editors,  Thieme, pp. 492-493, 1997

Discussion:  Cystic Hygroma is a benign congenital neck mass of lymphatic origin. Cystic hygroma can range from a small isolated mass to a massive lesion. The clinical picture is usually the one of an asymptomatic mass.

Cystic hygroma are usually present at birth. 70-80% of these lesions are diagnosed by the second or third year of life. Males and females are affected equally.

Depending of the size and location, associated symptoms (such as dyspnea, dysphagia, stridor) can occur due to compression of the upper aerodigestive tract and/or other anatomic structures (facial deformities due to mass effect noted in this patient).

The diagnosis is usually evident on physical examination and confirmed by CT scanning or MRI andultrasonography.

The treatment is usually surgical, preventing any damage to the adjacent vital structures of the neck (in this case: facial nerve, accessory nerve, internal jugular vein).

The case presented required a dissection of the lower division of the facial nerve and a neck dissection at level II of the neck. The level II of the neck is localized in the corner between the sternocleidomastoid muscle and the posterior belly of the digastric muscle.  The anatomic structures at this level (surrounded by fibro-fatty tissue) are:  accessory nerve and the upper third of the internal jugular vein.

Acknowledgment:

To all of the patients who have taught me so much.

To Dr. Juan Portela for his participation and assistance in the case.

Any comments or questions regarding the above,

please notify at  ariera@spray.no