Torticollis
DR PABITRA KUMAR SAHOO, ASSISTANT PROFESSOR(PMR)
The word “torticollis” itself comes from two Latin root words, “tortus” and “collum,” that
together mean “twisted neck.” This condition, sometimes called wryneck, is relatively common
in children. In general, torticollis is classified as-
Congenital-present at birth
Acquired -occurring later in infancy or childhood
Congenital muscular torticollis
Aetiology
The etiology is incompletely understood, although several theories have been
postulated.Reports on the familial transmission of congenital muscular torticollis have
been few. An idiopathic intrauterine embryopathy or the intrauterine development of
sternocleidomastoid compartment syndrome may be responsible for the sternomastoid
fibrosis. Birth trauma or intrauterine malposition is considered to be the cause of damage
to the sternocleidomastoid muscle in the neck.
Pathophysiology
An end-arterial branch of the superior thyroid artery supplies the middle part of the
sternocleidomastoid muscle. Obliteration of this end artery may be responsible for the
development of muscle fibrosis. As an alternative, primary trauma that temporarily and
acutely obstructs the veins may lead to intravascular clotting in the obstructed venous
tree. In infants, this clotting is evidenced by the development of a sternocleidomastoid
mass.
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Acquired torticollis
spasmodic (clonic)
permanent (tonic).
Causes-
A self-limiting spontaneously occurring form of torticollis with one or more painful neck
muscles is by far the most common ('stiff neck') and will pass spontaneously in 1–4
weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved.
Sometimes draughts, colds or unusual postures are implicated; however in many cases no
clear cause is found.
posterior fossa tumors of the skull base can compress the nerve supply to the neck and
cause torticollis.
Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and
cause torticollis.
Ear infections and surgical removal of the adenoids
The use of certain drugs, such as antipsychotics, can cause torticollis.
Antiemetics - Neuroleptic Class –Phenothiazines
Clinicalfeatures
The mass is generally 1-3 cm in diameter. It is a painless swelling in the substance of the
sternocleidomastoid muscle and develops in neonates aged 2-3 weeks. In infants, the tumor is
hard, and the patient's head is tilted and flexed to the side of the fibrosis. However, in older
children, the tumor is less discrete than it is in younger children, and the sternocleidomastoid
muscle appears thickened and shortened along its entire length. This thickening restricts rotation
and lateral flexion of the neck (Figure-1). This rotation and lateral flexion of the neck is largely
responsible for the gradual increase in positional plagiocephaly.
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Older children compensate for the head tilt by elevating their shoulder to maintain a horizontal
plane of vision. The head tilting is further compensated by twisting the neck and back, if
required, to maintain a straight line of sight(Figure-2). These compensatory mechanisms do not
occur in infants, who do not need to maintain a horizontal plane of vision until they stand up.
Also, in older patients, muscular spasms play a role or accompany torticollis
(Figure-1) (Figure-2)
Treatment
Nonsurgical:
Management for torticollis is primarily nonoperative, generally consisting of parental
physiotherapy. 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. There are other postural exercises that can be helpful. Position toys where the baby
has to turn his or her head to see them. Carry the child so that he or she looks away from the
limited side. Position the crib so that the child must look away from the limited side to see
outside the crib.
Surgicaltreatment
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Surgical management of congenital muscular torticollis is generally avoided until the child is
aged at least 1 year, until conservative methods (eg, physiotherapy) are unsuccessful, and until
other differential diagnoses are excluded. . The procedure will lengthen the short
sternocleidomastoid muscle by releasing the distal insertion site at sternoclavicular end, called
unipolar release(Figure-3). In girls the sternal end is tried to preserve as a symbol of beauty or
lengthen by Z plasty. In more elderly children, releasing distal end may not be sufficient and
proximal release at occipital attachment is required, called bipolar release. Post operatively head
halters traction is required to mentain the correction followed by use of a modified cervical
brace(Figure-4 &5).
Figure-3 Figure-4 Figure-5
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