Lesson outcomes
Define torticollis.
Discuss the causes of torticollis.
Describe the clinical manifestation and diagnosis of torticollis.
Outline the management of torticollis.
TORTICOLLIS
derived from the Latin words tortus (twisted) and collum (neck)
Definition:
Torticollis (wry neck) is caused by
involuntary, unilateral contraction of the neck muscles, particularly the
sternocleidomastoid (SCM) and trapezius
Causes
There are four basic forms of torticollis
1. Congenital torticollis
2. Acquired torticollis
3. Spasmodic torticollis
4. Acute torticollis
Congenital torticollis
occur in newborns as a result of muscle injury at birth
Intrauterine malposition
malformation of the cervical spine, and other causes (e.g., spina bifida, Arnold-Chiari syndrome)
Muscle injury is the most common cause of congenital torticollis and is referred to as congenital muscular torticollis (CMT)
Risk factors:
large infants
infants in breech presentation
infants with hip dysplasia
infants presenting in a difficult vertex position
multiple birth (e.g., twins, triplets)
maternal uterine abnormalities
Congenital Muscular Torticollis (CMT)
Acquired torticollis
occurs secondary to injury, inflammation, or infection
children under the age of 10 years
caused by muscle trauma
spinal syrinx (i.e., a fluid-filled cyst)
a central nervous system tumor
an inflammatory condition (e.g., juvenile idiopathic arthritis), or an
upper respiratory infection associated with inflammation of the neck muscles
Older children and adults
can occur secondary to myositis,
lymphadenitis tonsillitis, pharyngitis
dystonias, cervical spine injuries
vestibular dysfunction, ocular disorders
tumors of the head or neck
Spasmodic torticollis
also known as Cervical Dystonia
unknown etiology
characterized by a painful progressive involuntary contraction of the SCM.
This spasm may be sustained or recurrent
Cervical dystonia is a neurologic
movement disorder that may have a genetic link and is thought to be a
“faulty guarding mechanism”
Acute torticollis
results from a cervical spine facet joint restriction
generating a cycle of pain, inflammation and more restriction
precipitated by a minor traumatic insult like sleeping in an awkward position or sleeping under a draft from an open
window or fan.
Patients will sometime report a history of unusual or strenuous activity the day
before, i.e. new exercises, travel,
prolonged head rotation during a movie, etc.
Clinical manifestations
abnormal twisting of the neck
shortening or excessive contraction of the sternocleidomastoid muscle
head is typically tilted in lateral bending toward the affected muscle and
rotated toward the opposite side
Congenital torticollis- usually painless
baby’s head may be flattened as a result of remaining in one position
(plagiocephaly)
Acute torticollis- painful
Acute/ Acquired torticollis
loss of range of motion
extension and lateral flexion into the side of pain is significantly limited
chronic numbness and tingling in the upper limbs may develop due to
pressure on the nerve roots
Headache, neck pain
Stiffness & swelling of the neck muscles
Symptoms of underlying causes
Diagnosis
history of trauma
birth history in congenital torticollis
neck & cervical spine X-ray
MRI- to detect structural problems or other conditions (eg. brain tumour)
Evaluation by an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision
problems
High-frequency and color Doppler
ultrasonography to confirm the diagnosis of CMT
Management
Congenital Torticollis
gentle motion of the head and neck to stretch the muscles
Physiotherapy
Strengthening exercises
Surgery- fail to respond to stretching and require surgical release of the
muscle
Acquired/ Acute Torticollis
Treat the underlying causes
Antibiotics for the specific infection
Rest, anti-inflammatory medications
Muscle relaxants
soft collar or brace to support the neck
Usually self-limiting, resolve spontaneously in 1–4 weeks
If there is inadequate response to physiotherapy and analgesics
or in the case of persistent pain and stiffness
Botulinum toxin injection
Benzodiazepine (e.g., clonazepam)
References:
https://next.amboss.com/us/article/kQ 0mwf#Zfae34d33cde5a60db36f5e5fc a5529e3
Schub T; Pravikoff D. Torticollis.
CINAHL Nursing Guide, EBSCO Publishing, 2018.
Quiz
1. A 3-week-old male infant is brought to the physician by his parents because they noticed that his head has been tilted to the left since birth.
Physical examination reveals the head turned toward the left and the chin rotated toward the right.
Which of the following is the most likely predisposing factor for the patient’s
condition?
A. Premature birth
B. Cesarean delivery
C. Fetal malpresentation
D. Congenital syphilis
Quiz
2.
List THREE (3) risk factors for congenital muscular torticollis (CMT).
Quiz
3. Regarding congenital torticollis all the statements are true except :
A. Always associated with breech delivery
B. Spontaneous resolution in most cases
C. 2/3rd cases have palpable neck mass at birth
D. Uncorrected cases develop plagiocephaly
Answers & Feedback
Q1:
Answer: C. Fetal malpresentation
Feedback: The patient is presenting with torticollis. The most likely to be a congenital torticollis because the baby is only 3-week-old and this abnormal neck position present since birth. Congenital torticollis are predisposed by fetal malpresentation and difficult delivery etc.
Cesarean delivery, premature birth or congenital syphilis doesn't increase risk of congenital torticollis.
Q2:
Risk factors for CMT
Breech presentation
Multiple births - twins
Increased birth wieght
Trauma at birth
intrauterine malpositioning
Answers & Feedback
Q3:
Answer:
A. Always associated with breech delivery
Feedback: Breech delivery is one of the predisposing factors of congenital
torticollis, but not always associated
with it. Most of the cases, it can resolve spontaneously and can present with
plagiocephaly and palpable neck mass at birth.