Torticollis

CHAPTER 16

Torticollis

Overview

• Torticollis (wry neck) is a condition in which the head is tilted toward one side and the chin is turned toward the other.

• The term is derived from Latin—torqueo, “to twist,” and collum, or “neck.”

• A spectrum of conditions may precipitate torticollis in a child. An appropriate history and physical examination (Table 16-1) will narrow the differential diagnosis. Congenital muscular torticollis is the most common type by far.

• The differential diagnoses can be separated into 2 broad categories.

— Congenital or newborn-associated conditions

— Acquired from causes including traumatic, infectious/inflammatory, and neoplastic conditions

• All patients with torticollis should undergo screening with the use of anteroposterior (AP) and lateral cervical radiographs.

Congenital Muscular Torticollis

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Congenital muscular torticollis is the most common form, with an incidence of 1% to 2% of live births.

• It is more common in boys and in breech presentation births.

• The right side is involved more often than the left.

• Etiology is unknown.

— Ultrasonographic studies suggest that intrauterine malpositioning may play a role by causing injury to the sternocleidomastoid muscle (SCM), leading to subsequent fibrosis (pseudotumor).

— Heredity may also be a factor.

— Other potential etiology includes trauma (eg, muscle stretch with intra-compartmental hemorrhage)

• Developmental dysplasia of the hip may coexist with congenital muscular torticollis at a rate of about 2% to 29%.

SIGNS AND SYMPTOMS

• Typically present at 2 to 4 weeks of age.

• The head is tilted toward the involved SCM, and the chin is tilted away (chin left and occiput right, or chin right and occiput left).

Table 16-1. History and Physical Examination Findings for Various Causes of Torticollis

History or Physical Examination Finding	Diagnoses to Consider
Present since birth	Congenital muscular torticollis Klippel-Feil syndrome/congenital cervical abnormality Neurogenic causes (eg, brain or spinal cord abnormalities)
First appears in late infancy	Ocular torticollis if painless and having full cervical range of motion
Sudden onset	Atlantoaxial rotatory subluxation Paraspinal soft tissue strain Other fractures and ligament injuries
Worsened over weeks or months	Neurogenic causes
Worsened over years	Klippel-Feil/congenital cervical abnormality
Intermittent	Neurogenic causes Sandifer syndrome Paroxysmal torticollis of infancy
History of trauma	Paraspinal soft tissue injury Atlantoaxial rotatory subluxation Other fractures and ligament injuries
Recent fever	Vertebral osteomyelitis or diskitis Grisel syndrome (inflammatory atlantoaxial rotatory subluxation)
Painful	Traumatic (see “History of trauma,” earlier) Atlantoaxial rotatory subluxation Other fractures and ligament injuries Grisel syndrome (inflammatory atlantoaxial rotatory subluxation) Diskitis/osteomyelitis Juvenile idiopathic arthritis Neoplastic conditions such as eosinophilic granuloma and osteoid osteoma/osteoblastoma
Flexible (no SCM contracture or range of motion deficit)	Ocular torticollis Sandifer syndrome
Neurologic signs or symptoms	CNS tumors (eg, cervical cord, brainstem, posterior fossa) Chiari malformation Syringomyelia Basilar invagination

Abbreviations: CNS, central nervous system; SCM, sternocleidomastoid muscle.

• A palpable, firm mass (pseudotumor), usually at the distal third of the SCM.

• Range of motion is decreased, especially rotation toward the tight SCM and lateral bending away from the tight SCM.

• When the defect is long-standing, plagiocephaly, facial asymmetry, and a unilateral epicanthal fold may be noted.

DIFFERENTIAL DIAGNOSIS

• Ocular torticollis

• Klippel-Feil/congenital cervical abnormality

DIAGNOSTIC CONSIDERATIONS

• Diagnosis is determined based on the history and physical examination findings (Table 16-1), the results of diagnostic tests, radiographs, or other imaging of the cervical spine, and, when appropriate, an eye examination.

• AP and lateral radiographs of the cervical spine are routinely obtained to rule out congenital anomalies of the cervical spine that may account for abnormal head position and limited cervical range of motion.

• Ultrasonography can help differentiate congenital muscular torticollis from other soft tissue pathologies in the neck, such as tumors or cysts, and help to define the extent of SCM fibrosis, which may be prognostic. Ultrasonography is performed only in select cases.

• A thorough hip examination and diagnostic imaging of the hips with ultrasonography or radiography should be included in the evaluation of children with congenital muscular torticollis.

TREATMENT

• Nonoperative

— Manual stretching is the treatment of choice and is 90% effective, particularly if the child is younger than 1 year.

— It also includes a home program of active stretching (after instruction by an occupational or physical therapist).

Only gold members can continue reading. Log In or Register to continue