Aetiology Various theories have been put forward, but the true cause is unknown:
Venous occlusion (most probable) – compartment syndrome of the muscle
Rupture of the sternocleidomastoid muscle and haematoma formation during labour
Intra-uterine malposition/compression causes pressure and ischaemia of the muscle, predisposing it to damage by a traumatic or even normal delivery
preponderance of first-borns, breech and difficult deliveries
Congenital defect in the development of the muscle anlage
Incidence 1 in 300 live births
equal sex and side incidence
Diagnosis made on average first 2-3 months.
30-40% develop a pseudotumor/swelling over SCM - usually discovered first 2-3 weeks of life.
The swelling may increase for two to four weeks and remain stationary for two to three months, gradually regressing and disappearing in four to eight months.
In a few cases, residual shortness of the SCM may remain, producing torticollis and asymmetry.
In another small group, torticollis may not be apparent until three or four years later when the neck elongates.
immature cellular fibrous tissue containing dispersed remnants of muscle tissue
Fully developed case
swathes of adult non-cellular fibrous tissue interspersed with living, healthy, muscle fibres
DDx other muscle – rarely trapezius and paraspinal muscles
osseous abnormalities; such as Klippel-Feil syndrome, hypoplasia of the lateral mass of C1, or atlanto-occipital abnormalities
Sandifer syndrome is characterized by gastroesophageal reflux and torticollis or tilting of the head, presumably an attempt on the child to be more comfortable. It may present in infancy or later childhood, usually in children with cerebral palsy.
Neurogenic tumors or malformations, of which posterior fossa lesions are most common.
Surgery is not advised for sternocleidomastoid tumour because most disappear
well accepted that patients older than 1 year with a definite tight band of the sternocleidomastoid muscle should be treated surgically, there is no consensus on the care of patients younger than 1 year of age.
Treatment of patients younger than 1 year of age ranges from prophylactic resection of the sternocleidomastoid tumor to observation alone until after the age of 1 year
Conservative Early physical therapy Optimally started before 6 months of age
Manual stretching is the most common form of treatment – stretching should NOT be painful and should be carried out by parents whenever possible
successful in over 80%
To avoid plagiocephaly
Adjuvant measures such as moulding helmet therapy, halo devices, and adjustable cervical collars (TOT collar) have been advocated with variable rates of success
Shown to be safe in children and effective when used after failure of conservative management
Surgical intervention is reserved for those patients that
presence of a tight band or tumor in the sternocleidomastoid muscle
fail to respond to physical therapy
progressive craniofacial growth asymmetry or severe neck angulation.
age >1 yr
There is general agreement that those patients that have muscular release before 1 year of age have the best chance of reversing their facial and skull deformities.
In long-standing cases over 1 year shortening of other structures may occur, and these structures include the trapezius, scalene, the platysma muscles, and the carotid sheath. It is important to recognize this fact because these structures may need to be released at operation to release the neck sufficiently to achieve a good result.
identification and release of all restricting bands involving the sternocleidomastoid muscle and other neck structures;
moving the head through a full range of motion before the completion of the procedure;
resuming physical therapy within 2 weeks of operation to prevent recurrent scar contracture.
complete excision of the SCM in infancy
tenotomy of the superior end of the muscle (superior open tenotomy)
some divide clavicular head and lengthen the sternal head
tenotomy at both superior and inferior ends (ie bipolar release)
bipolar release with excision of the proximal 2.5 - 4cm of the SCM
Ferkel et al (1983)
lengthening of the sternal attachment with a Z-plasty of the sternal head and complete division of the clavicular head
concomitant release of contracted bands of fascia and muscle (platysma / scalenus anterior / trapezius)
this is followed by head halter traction for 2 - 4 weeks, and a cervical collar holding the head in an overcorrected position for 3 - 4 months
Technique of inferior tenotomy
A transverse lower neck incision is made along skin lines about 1 cm above the clavicle, and the sternal and clavicular heads of the muscle are identified and usually both divided.
Range of motion of the neck at this time will bring into prominence any structures that may tether the neck, such as the trapezius, scalene, or platysma muscle, or the carotid sheath.
If any of these structures are shortened and tether the neck, they need to be released sufficiently under direct vision to allow full range of motion. Failure to do this may result in a suboptimal result.
Total or subtotal resection of the cosmetically important sternocleidomastoid column is not necessary and is deforming. Furthermore there is a significant risk of spinal accessory nerve or great auricular nerve injury.
Potential problems of inferior open tenotomy are hollowing at the base of the neck and a bony prominence of the sternal head of the clavicle. In practice, the occurrence of these deformities is highly variable and unpredictable.
great auricular nerve
spinal accessory nerne
facial nerve as mastoid is not well pneumatised (superior release)
external and internal jugular vein
diplopia may be present post-operatively
the patient’s equilibrium may be disturbed for a few days
In general, the earlier the age in childhood at which the operation is performed, the better are the results, although good results have been reported in late childhood as well.
Earlier operation not only improves head tilt, neck bands, and loss of normal neck contour, but also prevents craniofacial asymmetry that appears to result from restricted growth on the affected side.
A release of the sternocleidomastoid muscle by division of its upper insertion at the mastoid process has the advantage of a well-hidden retroauricular scar and maintenance of lower neck fullness. In early childhood, the mastoid cells are not pneumatized, and the facial nerve is at risk for injury here.
Muscle lengthening procedures have been touted. An advantage to this procedure is the maintenance of the cosmetically important lower neck sternomastoid column fullness.
Total sternomastoid excision also has been described, but is no longer used routinely because of significant postoperative neck asymmetry and complications such as spinal accessory nerve or great auricular nerve injury.
In most patients an improvement in the aesthetic deformity is the primary objective.
Fig. 1. Drawing of child with various surgical incisional approaches marked with dotted lines. (A) Scalp incision for endoscopic approach. (B) Postauricular incision for superior pole release. (C) Incision for mid muscular transection. (D) Supraclavicular incision used for lower pole release or lower part of bipolar release.
superficial wound infection
tethering of the scar
loss of the sternocleidomastoid muscle contour
formation of lateral band.
More likely to recur during growth spurts when treated conservatively