Torticollis
DEFINITION:
Torticollis
or wryneck is the term used to describe a twisted or turned
neck. Torqueo means twist and collum means neck.
SYMPTOMS:
Head tilted to one side with the inability to straighten it.
CAUSES:
There are many causes for the neck to be tilted to one side.
The most common is muscular torticollis caused by a shortening
or contracture of a muscle in the neck called the sternocleidomastoid
muscle. This cause is usually due to birth trauma, poor positioning
of the baby in the uterus, or injury. However there are many
more causes for the head to be tilted to one side. Congenital
malformations of the cervical spine in infancy, trauma, and
masses in the neck can also cause torticollis. See the table
below taken from Nelson's Textbook of Pediatrics, volume 16,
page 2090 for a full list of causes.
CONTAGION:
Not
contagious.
Differential
Diagnosis of Torticollis (Wryneck)
Congenital
Muscular
torticollis
Positional deformation
Hemivertebra (cervical spine)
Unilateral atlanto-occipital fusion
Klippel-Feil syndrome
Unilateral absence of sternocleidomastoid
Pterygium colli
Trauma
Muscular injury (cervical muscles)
Atlanto-occipital subluxation
Atlantoaxial subluxation
C2-3 subluxation
Rotary subluxation
Fractures
Inflammation
Cervical lymphadenitis
Retropharyngeal abscess
Cervical vertebral osteomyelitis
Rheumatoid arthritis
Spontaneous (hyperemia, edema) subluxation with adjacent head
and neck infection (rotary subluxation syndrome)
Upper lobe pneumonia
Neurologic
Visual
disturbances (nystagmus, superior oblique paresis)
Dystonic drug reactions (phenothiazines, haloperidol, metoclopramide)
Cervical cord tumor
Posterior fossa brain tumor
Syringomyelia
Wilson's disease
Dystonia musculorum deformans
Spasmus nutans
Other
Acute cervical disk calcification
Sandifer syndrome (gastroesophageal reflux, hiatal hernia)
Benign paroxysmal torticollis
Bone tumors (eosinophilic granuloma)
Soft tissue tumor
Hysteria
DIAGNOSIS:
The
diagnosis is made during physical examination. If the head
is tilted to one side and cannot be straightened, this is
torticollis.
TREATMENT:
Treatment will depend on the underlying cause. If the cause
is a shortening or contracture of the sternocleidomastoid
muscle, then the first step is physical therapy to stretch
the sternocleidomastoid muscle. Sometimes this fails and surgical
correction is necessary. If the cause is a congenital malformation
of the cervical spine, an x-ray will need to be taken and
stretching or surgical correction may be necessary. Any of
the other treatment options would depend on the underlying
cause. Mostly, the treatment would consist of treating the
underlying problem followed by stretching, physical therapy,
or surgical correction.
OUTCOME:
The
most common cause is muscular torticollis and most will resolve
with physical therapy. The sooner physical therapy is started
the better, preferably under one-month of age. If physical
therapy fails, surgery will correct the problem. The other
causes can be more difficult to treat and each can have a
different outcome depending on the severity of the underlying
cause.
DISCUSSION:
Muscular torticollis is noticeable at birth due to the inability
of the infant to turn its head in all directions. The head
is tilted toward the problem muscle. It's not known exactly
why this happens, but the most common explanation is that
the baby is positioned improperly in the uterus. Nothing can
be done to prevent that so this problem must be treated when
it is noticed. Physical therapy is the best way to start treatment.
A physical therapist can teach the parents proper stretching
techniques to stretch the effected muscle. With physical therapy
most muscular torticollis will resolve. If it fails, surgical
correction may be necessary. Many surgeons are performing
the surgery endoscopically so there is minimal scarring on
the skin. Others still like to do open surgery, which has
been done successfully for many years, but will leave a larger
scar on the skin of the neck. Once corrected, this problem
should not recur. Causes of congenital torticollis other than
muscular torticollis, trauma, inflammation, neurologic problems,
and all of the other causes can be more difficult to treat.
If the underlying problem can be corrected then that is the
preferable route. If not, then strengthening exercises and
ultimately surgery may be helpful in some cases.
ONE DOCTOR'S OPINION:
Torticollis
may be difficult to detect at birth. The baby may be moving
during a physical examination and it may easily go unnoticed.
This is where parental history is so important. Most cases
of torticollis are diagnosed after a parent mentions to the
physician that the child always looks in only one direction.
Then if the physician cannot move the head in all directions,
a diagnosis of torticollis can be made. For muscular torticollis,
a visit to the physical therapist and vigorous stretching
by the parents should solve this problem. If not, surgery
will fix it. My choice would be by endoscopy to leave a minimal
scar. Once fixed, it will not come back. For the other causes
of torticollis, individual therapy will have to be tailored
for each child depending on the cause. The bottom line is,
if your child's head is tilting to one side, visit your physician
and tell your physician about this finding. That would be
the best way to get the best and most immediate help for your
child. Untreated torticollis can lead to long-term problems
including loss of motion of the neck, undiagnosed neurologic
problems, untreated inflammatory disease, and loss of function
in the child.
