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The treatment of giant cystic hygroma of the neck
British Jourmd of l'lostir Sm~gery(z 973), 26, 6~j-7t
THE T R E A T M E N T OF GIANT CYSTIC H Y G R O M A OF T H E NECK By B. S. CRAWFO~r~,M.B., F.R.C.S. and C.
VIVAKANANTHAN,
M.B., F.R.C.S., F.R.C.S.E. 1
Plastic and Jaw Department, The Royal Hospital Annexe, Fulwood, Sheffield IN the past this rare condition was treated by the injection of sclerosants, by radiotherapy or by surgery. At present surgical excision after the age of I8 months to 2 years is recommended as the treatment of choice if spontaneous resolution has not occurred. Occasionally aspiration with or without tracheostomy is indicated as an emergency in infants with severe respiratory difficulty. Broomhead (I964) recorded 44 cases of cystic hygroma, large and small arising in various anatomical sites. Of these, 7 underwent spontaneous resolution and 9 were cured
FIG. ~ FIG. 2 FIG. I. T h e Aiken insulated diathermy needles, one pointed and one ball-ended. FIG. 2. T h e aspirating needle and diathermy needle in sire.
by zotal excision. In 23, parts of the cyst were left behind after excision and of these 13 remained apparently free from recurrence. There were 5 deaths. Complications included nerve palsies, infection, haemorrhage and in one case damage to thc oesophagus. These figures are probably better than any previously published, but the mortality and recurrence rate are still high for a benign condition; The treatment of giant cystic hygroma by the method to be described was inspired by our success with the treatment of the common angiomas which had not resolved spontaneously by a diathermy needle, insulated apart from the tip (Aiken, I95 o) so that deep coagulation can be carried out without skin damage. Treatment is performed under general anaesthesia at intervals of a few months. A current of low intensity is applied for about 2 seconds to the lining of the cysts at each of a number of sites. Manipulation Present address: Plastic Surgery Unit~ Middlesbrough General Hospital, Middlesbrough. 69
70
B R I T I S H j O U R N A L OF P L A S T I C SU RG E RY
FIG. 4 FIG. 3 FIG. 3. Case I before treatment. FIG. 4- Case I at the age of 7 years.
FIG. 5 FIG. 6.
FIG. 6
FIG. 5- Case 2 before treatment. Case 2 after three applications o f diathermy.
of the lesion in one hand and the needle in the other enables various parts of the hygroma to be treated. Partial aspiration of the larger cysts makes it easier to make contact between the lining and the needle and the use of a ball-ended electrode introduced through one or more short stab incisions increases the area coagulated (Figs. I and 2).
TtIE T R E A T M E N T OF G I A N T C Y S T I C H Y G R O M A OF THE NECK
71
The theatre lights are dimmed so that the glow of the electrode can be observed; its presence and a feeling of heat indicate that the skin is in danger. Care is taken to avoid important structures such as the external jugular vein and the carotid sheath, and no attempt is made to treat the deep-seated loculi. It is impossible to destroy the entire lining, but this is found to be unnecessary in practice. The treatment is not prolonged fbr more than about IO minutes; otherwise the insulated part of the needle may heat up from conduction from the tip and endanger the skin at the site of entry. The hygroma, which is collapsed at the end of the operation, rapidly refills with fluid but this does not indicate failure. Signs of obliteration are noticed within a month. They take the form of skin wrinkling, a doughy feeling of the cysts and loss of transillumir,~.tion. After a few months, the areas which still transilluminate can be treated again. Admission is normally for 48 hours on each occasion. Our first case needed z treatments with diathermy and an operation to remove redundant skin. She was followed up for 7 years without recurrence (Figs. 3 and 4). The second case has had 3 treatments and will probably require a fourth to clear up a persistent cyst overlying the mastoid; this will be combined with a trimming operation to remove excess skin from the submandibular region (Figs. 5 and 6). SUMMARY AND CONCLUSIONS
It is unwise to draw conclusions from 2 cases in a condition in which spontaneous resolution is possible, but we consider that the method described is worthy of further trial because of its simplicity and ease of application. REFERENCES AMEN, D. (195t). D i a t h e r m y treatment of angiomata. British Medical Journal, ii, 11231125 . BROOMHEAD,I. (X964). Cystic hygroma of the neck. British Journal of Plastic Surgery, I7, 225-244.
THE T R E A T M E N T OF GIANT CYSTIC H Y G R O M A OF T H E NECK By B. S. CRAWFO~r~,M.B., F.R.C.S. and C.
VIVAKANANTHAN,
M.B., F.R.C.S., F.R.C.S.E. 1
Plastic and Jaw Department, The Royal Hospital Annexe, Fulwood, Sheffield IN the past this rare condition was treated by the injection of sclerosants, by radiotherapy or by surgery. At present surgical excision after the age of I8 months to 2 years is recommended as the treatment of choice if spontaneous resolution has not occurred. Occasionally aspiration with or without tracheostomy is indicated as an emergency in infants with severe respiratory difficulty. Broomhead (I964) recorded 44 cases of cystic hygroma, large and small arising in various anatomical sites. Of these, 7 underwent spontaneous resolution and 9 were cured
FIG. ~ FIG. 2 FIG. I. T h e Aiken insulated diathermy needles, one pointed and one ball-ended. FIG. 2. T h e aspirating needle and diathermy needle in sire.
by zotal excision. In 23, parts of the cyst were left behind after excision and of these 13 remained apparently free from recurrence. There were 5 deaths. Complications included nerve palsies, infection, haemorrhage and in one case damage to thc oesophagus. These figures are probably better than any previously published, but the mortality and recurrence rate are still high for a benign condition; The treatment of giant cystic hygroma by the method to be described was inspired by our success with the treatment of the common angiomas which had not resolved spontaneously by a diathermy needle, insulated apart from the tip (Aiken, I95 o) so that deep coagulation can be carried out without skin damage. Treatment is performed under general anaesthesia at intervals of a few months. A current of low intensity is applied for about 2 seconds to the lining of the cysts at each of a number of sites. Manipulation Present address: Plastic Surgery Unit~ Middlesbrough General Hospital, Middlesbrough. 69
70
B R I T I S H j O U R N A L OF P L A S T I C SU RG E RY
FIG. 4 FIG. 3 FIG. 3. Case I before treatment. FIG. 4- Case I at the age of 7 years.
FIG. 5 FIG. 6.
FIG. 6
FIG. 5- Case 2 before treatment. Case 2 after three applications o f diathermy.
of the lesion in one hand and the needle in the other enables various parts of the hygroma to be treated. Partial aspiration of the larger cysts makes it easier to make contact between the lining and the needle and the use of a ball-ended electrode introduced through one or more short stab incisions increases the area coagulated (Figs. I and 2).
TtIE T R E A T M E N T OF G I A N T C Y S T I C H Y G R O M A OF THE NECK
71
The theatre lights are dimmed so that the glow of the electrode can be observed; its presence and a feeling of heat indicate that the skin is in danger. Care is taken to avoid important structures such as the external jugular vein and the carotid sheath, and no attempt is made to treat the deep-seated loculi. It is impossible to destroy the entire lining, but this is found to be unnecessary in practice. The treatment is not prolonged fbr more than about IO minutes; otherwise the insulated part of the needle may heat up from conduction from the tip and endanger the skin at the site of entry. The hygroma, which is collapsed at the end of the operation, rapidly refills with fluid but this does not indicate failure. Signs of obliteration are noticed within a month. They take the form of skin wrinkling, a doughy feeling of the cysts and loss of transillumir,~.tion. After a few months, the areas which still transilluminate can be treated again. Admission is normally for 48 hours on each occasion. Our first case needed z treatments with diathermy and an operation to remove redundant skin. She was followed up for 7 years without recurrence (Figs. 3 and 4). The second case has had 3 treatments and will probably require a fourth to clear up a persistent cyst overlying the mastoid; this will be combined with a trimming operation to remove excess skin from the submandibular region (Figs. 5 and 6). SUMMARY AND CONCLUSIONS
It is unwise to draw conclusions from 2 cases in a condition in which spontaneous resolution is possible, but we consider that the method described is worthy of further trial because of its simplicity and ease of application. REFERENCES AMEN, D. (195t). D i a t h e r m y treatment of angiomata. British Medical Journal, ii, 11231125 . BROOMHEAD,I. (X964). Cystic hygroma of the neck. British Journal of Plastic Surgery, I7, 225-244.