Approach to Torticollis

Answer 1

• Definition: lateral head tilt with rotation of the chin to the opposite side
• Congenital or Acquired
• Many resolves spontaneously, but some require work up

Answer 2

Congenital Muscular Torticollis:

• 2% of newborns, M>F, right> left
• Result of unilateral shortening of SCM – fibrosis of the muscle following traumatic birth
• Non-tender mass – fibromatosis coli - will be noted within first 4 weeks of life, usually resolve within the first year of life.
• Related to intrauterine/ perinatal events – can be checked up on ultrasound, variable appearance on MRI and CT to be avoided.
• Associated disorders
  
  • Bony abnormalities of c- spine c1+c2
  • Congenital alanto- occipital abnormalities
  • Webbing of the neck
  • DDH(20%)
  • Metatarsus adductus
  • Flat face on contracted SCM side – sleeping position
  • Klippel- feil syndrome ( triad: short neck, low hairline, restricted neck movement), chiari malformation
• Differential Diagnosis
  
  • Grisel’s syndrome -
  • Rigid torticollis

Answer 3

• Differential Diagnosis
  
  • Grisel’s syndrome -
  • Rigid torticollis

Question 4

Management of torticollis

Answer 4

• Non-operative
  
  • Passive stretching – 90% respond, bending and rotational opposite to deformity
  • Only indicated if condition present for <1 year, and limitation <30deg.
• Operative
  
  • Failed of non-operative – after 12-24months of age, surgery required to prevent facial deformity
  • Transverse incision in the neck through skin fold
  • Resect the distal portion of SCM from sternal and clavicle attachments
  • Alternative – z-plastic lengthening

Question 5

Complications of torticollis

Answer 5

• Permanent rotational deformity
• Positional plagiocephaly
• Facial asymmetry
• Dysplasia – skull base, atlas, axis

Question 6

Acquired Torticollis

Answer 6

• Typically between 5 and 12
• All causes need to be excluded before idiopathic spasmodic torticollis is diagnosed
• Causes
  
  • Infection: cervical OM, retropharyngeal abscess, grisels disease - AARS
  • Tumours
  • Trauma: occipital condyle fractures, muscle spasm, peg fractures
  • Cervical disc disease
  • Drug induced: L-dopa and neuroleptics
  • Ocular conditions: inf oblique muscle palsy- held at an angle to correct vision
  • Essential head tremor

Question 7

Investigations

Answer 7

• Xrays
• MRI
• CT
• blood work

Question 8

Management

Answer 8

• Treat the cause
• Generally resolve within several days to weeks – persistent requires surgery.
• Passive stretching and exercises, orthotic collar
• Medical: muscle relaxants- benzo, anticholinergics, local botox.
• Surgery:
• Selective cases – upper cervical nerves severed