The slanting neck can be divided into congenital muscular slanting neck and congenital bony slanting neck. The former is a congenital neck deformity caused by contracture of the sternocleidomastoid muscle on one side, which is quite common; the latter is a congenital squint due to malformation of cervical vertebrae development, which is less common.
Introduction
Slanting neck is characterized by head tilt to the affected side, forward tilt and facial deformation. A few are bony squint caused by spinal deformity, compensatory postural and neurological squint due to visual impairment and cervical muscle paralysis, except for myoclinal squint caused by contracture of sternocleidomastoid muscle on one side in general.
Most scholars believe that the sternocleidomastoid is related to injury, such as breech birth and fetal malposition, compression of the sternocleidomastoid muscle in the neck, vascular compression and ischemia, embolism of the arterial lumen of the sternocleidomastoid muscle on the affected side, resulting in muscle dysplasia, or muscle edema, inflammation, degeneration of myocytes, fibrous degeneration, and eventually replaced by connective tissue, resulting in contracture. Children with slanting neck often have congenital factors such as deformed feet and hip dislocation. If left untreated, the deformity becomes more pronounced as the child grows older.
The diagnosis of squint is usually not difficult. After birth, a poke-shaped swelling is found on one side of the neck, which is oriented in the same direction as the sternocleidomastoid muscle. The head and face deformity is first noticed a few months later, with tension haunting strips in the neck.
For children with oblique neck, passive pulling can be started two weeks after birth to correct the deformity by inclining the child’s head to the healthy side so that the healthy side of the earlobe is close to the shoulder and performing movements in the opposite direction to the deformity. The child’s head should be inclined to the healthy side so that the earlobe on the healthy side moves closer to the shoulder, and the movement is performed in the opposite direction of the deformity. Breastfeeding, sleeping pillows and toys to attract the child’s attention in daily life can correct the posture, and physical therapy can be used if possible.
For children over one year old, surgery is required to cut off the sternal and clavicular heads of the contracted sternocleidomastoid muscle, as well as the lower 1/2 canal of the muscle. After surgery, it is necessary to continue to correct and maintain the normal posture of the head and neck in order to achieve good results.
Clinical manifestations
1. Oblique neck deformity
After birth, the mother may find that the child’s head is tilted to the affected side, the face is rotated to the healthy side, the jaw points to the healthy shoulder, and after 2-3 weeks, the oblique neck.
The deformity becomes more obvious, and turning the head to the healthy side is obviously restricted. This symptom can only be detected by careful observation if the symptoms are mild, and it becomes increasingly aggravated with the growth and development of the child.
2. Neck mass
The neck mass is usually palpable after birth or within 2 weeks after birth and is located in the middle and lower part of the sternocleidomastoid muscle, with the right side being the most common. It usually reaches its maximum size after 1 to 2 months, and then gradually shrinks until it disappears completely. Some of these children may have masses that do not disappear and produce muscle fibrosis and contracture, resulting in oblique neck deformity.
3.Facial deformity
Facial deformity will appear after 2 years of age if congenital myotonic squint is not treated effectively in early stage, mainly manifesting as facial asymmetry, asymmetric distance from the outer corner of the eyes to the corner of the mouth on both sides, shortening the distance on the affected side and growing on the healthy side, lowering the position plane of the affected side of the eyes, and because both eyes are not on the same level, it is easy to produce visual fatigue and vision loss. The healthy side of the face is round and full, while the affected side is narrow and flat, and the cervical vertebrae may have compensatory scoliosis deformity. In addition, asymmetric changes may occur throughout the face, including the nose and ears.
In addition to the main manifestations mentioned above, congenital dislocation of the acetabulum and other deformities of the cervical spine may be combined with this condition.
Surgical treatment
1.Surgical indications and contraindications.
(1) Applicable to those who have failed to receive conservative treatment over half a year old.
(2) For people under 12 years old with obvious oblique neck deformity.
(3) If the facial deformity is not serious above 12 years old, surgery can be considered.
(4) For adults, because the deformity has existed for many years, not only will the facial deformity be more obvious after surgery, but also the vision will be changed because it is not adapted to the new postoperative position, so surgery is not recommended.
2. The following surgical methods are mainly available.
(1) Sternocleidomastoid excision is one of the more commonly used surgical methods. A transverse incision is made on the clavicle to reveal the sternocleidomastoid head and the clavicular head, and the attachment point is cut above, and the surrounding fascial tissue is released.
(2) Sternocleidomastoid muscle partial excision For obvious neck mass, the mass segment of sternocleidomastoid muscle can be excised.
(3) Total sternocleidomastoid resection For adolescent patients, if the entire sternocleidomastoid muscle is scarred, the whole segment can be removed.
(4) Sternocleidomastoid lengthening is to cut the clavicular head of the sternocleidomastoid muscle and lengthen the sternal head in a “Z” shape. The advantages of this surgery are
(1) correction of head and neck distortion and restoration of normal neck function.
(2) It does not destroy the normal cervical triangle body shape, avoiding other surgical methods to leave the neck depression deformity or abnormal flat deformity, making the neck beautiful and symmetrical.
(5) Combined release of upper and lower sternocleidomastoid muscle plus plication.
Ferkel et al. suggested that this procedure could be used in older children or in those who failed other procedures. The method is to completely cut off the papillary side of the sternocleidomastoid muscle and the head side of the clavicle, and to extend the head side of the sternum in a “Z” shape.
3.Postoperative treatment of severe oblique neck deformity and uncooperative children need to be corrected by head-neck-thorax cast to maintain the position of the child.
Conservative treatment
Pediatric strabismus is a relatively common congenital disease of the head and neck of children.
1. The earlier the better. Young mothers and fathers must keep an eye on their little one after birth and must see if he has a mass in his neck if his head is always tilted to one side. Once it is a squint, don’t panic and go to the doctor as soon as possible. One day earlier treatment will increase the hope of successful treatment.
2. Local medication closure is performed. This is very obvious to promote the absorption of the local mass, often choose prednisolone or hyaluronidase, plus an appropriate amount of lidocaine for local closure. Because it is in the neck, the injection should be very careful.
The drug should be injected in the center of the lump, not too deep injection, so as not to cause accidents by injecting into the blood vessels. If the injection is too shallow under the skin, in addition to being useless, it is also likely to cause infection at the injection site. At the beginning, because of the hard texture of the mass, the resistance to injection is high and should be pushed slowly. Generally, once a week, most children can gradually disappear the lump with 6 times. However, the effect may not be obvious for some people who are not sensitive to drugs or those who are treated late.
3.Local massage. Apply talcum powder and massage the lump repeatedly with the thumb or index finger in the lump.
4.Continue to turn the head repeatedly to keep the head and neck in a corrected position, which is very important for treatment. The specific method is: ~ 50 times a day, can be done in parts. When doing so, put the child flat on the bed, the parents hold his head with both hands and turn his jaw to the affected shoulder (i.e. at the neck mass), pause for about 1 minute after turning, so that the muscles are in the elongated and stretched state, and then turn again and again. However, in the process of turning, the technique should be gentle and prevent the use of violence to prevent damage to the neck muscles and even the cervical vertebrae. You can make 2 small sandbags (with green or yellow sand, cleaned with water, placed in the sun or heated with an iron pot to sterilize. Choose a double layer of cloth sewn, the diameter of about 20 x 10 cm size can be), the sandbags placed on both sides of the child’s head while sleeping, can be fixed in a corrected position. This treatment should last for more than 6 months.
5, the mother should choose her own position in relation to breastfeeding and sleeping according to the position of the different lesions. For example, if the child has a right-sided sloping neck, you should put the child on your left side during feeding and sleeping, and vice versa. This will facilitate the correction of the affected child.
It should be told that any method can be successful or unsuccessful, and if conservative treatment fails, you should choose to undergo surgery, mostly at the age of about 1 year, preferably no older than 1.5 years. Surgery can also achieve the desired therapeutic effect.