Torticollis

Dr. Öğretim Üyesi Dr. Selin Özen

1
 Introduction
Torticollis-
a type of movement disorder in which the muscles controlling
the neck cause sustained twisting or frequent jerking

Derived from Latin words of ‘torti’ (twisted) and ‘collis’ (neck)

First described by Alfred H. Tubby in 1912 as hereditary or

acquired

2
 Torticollis: The Clinical Picture
Torticollis is often the term used to
describe the clinical picture which arises
due to shortening of the
sternocleidomastoid muscle (SCM)
resulting in ipsilateral tilting of the head
and contralateral rotation of the face and
chin

3
 Torticollis: Epidemiology
Incidence of torticollis: 1/259 live births

Prevalence: 0.3-2%

Male: female – 3:2

Occurs more commonly on the right side of the body

Torticollis and hip dysplasia coexist in 0-20% of cases

4
 Torticollis: Aetiology in Childhood
Local causes
Congenital Compensatory causes
Muscular Strabismus due to IV cranial nerve palsy
Absence/hypertrophy of cervical muscles kasların Congenital nystagmus
Spina bifida Posterior fossa tumour
Arnold-Chiari syndrome
Congenital anomaly of cervical vertebrae konjenital
Cervical spinal tumour
anomalileri Weakness of extraocular muscles
Klippel-Feil syndrome
Otolaryngological pathologies
Central causes
Oesophageal reflux (Sandifer syndrome) Cervical torsion dystonia
Trauma Tardive dyskinesia
Birth trauma Cerebral palsy
Cervical fracture/dislocation Benign paroxysmal torticollis of childhood
Fracture of the clavicle
Subarachnoid bleed, epidural heamatoma
Spinal cord tumour
Juvenile rheumatoid arthritis
5
 Congenital Muscular Torticollis

Congenital muscular torticollis (CMT) occurs due to ipsilateral

shortening of the SCM

CMT 3rd most common congenital deformity

6
 Mac Donald Classification of Congenital Muscular
Torticollis

1- Fibromatosis colli or SCM tumour- 50% of CMT cases. Hard, painless palpable
fusiform muscle mass (pseudotumour)

E/K= 1.5:1, most right sided, 2-8% bilateral

Diagnosed 2-3 weeks postnatally, mostly disappears at 4-6 months

2- Muscular torticollis (30%) – Tense SCM ve reduced passive range of motion

(ROM) of the neck in the absence of a palpable mass

7
 Mac Donald Classification of Congenital
Torticollis
3- Postural torticollis (20%)
No mass or muscle shortening
Clinical picture resolves within a few weeks
May develop secondary to perinatal palgiocephaly
On examination, passive cervical ROM is normal with reduced
active rotation and lateral flexion of the neck
Tilting of the head occurs intermittently
8
 Aetiology of Congenital Muscular Torticollis

CMT Aetiology under debate (environmental vs. genetic factors)

Foetal malposition
Vascular phenomenon (SCM ischaemia)
Peripartum fibrosis following bleed
Compartment syndrome
Infection
CNS pathologies (inc. primary myopathy of the SCM)
9
 Prenatal/ perinatal causes of CMT
Difficut delivery (30-60%)

1st born

Reduced foetal movements

Oligohydramnios

Breech presentation

Forceps/ventouse delivery
10
Large baby
 Clinical Picture of CMT

Head bent to affected side

Chin facing opposite direction
Ipsilateral shoulder elevation
Palpable mass in SCM
Craniofacial deformity

11
 Craniofacial Deformities
Plagiocephaly- asymmetric cranium
Malformation

Deformation – positional/ functional

12
 Metamorphic Changes Accompanying CMT
Ipsilateral inferoposteriorly placed ears (94%)

Flattening of the occiput (80-90%)

Zygomatic bone asymmetry (87%)

Muscle asymmetry (81%)

Deviation of the chin (44%)

Asymmetry of the eyes (31%)

Deviation of the tip of the nose (19%)

13
 Changes in Motor Function in CMT

Delayed gross motor function due to head tilt affecting chest,

abdominal muscles and postural control and development of

movement and sensory motor coordination Reduced cognitive

function

Reduced postural control and balance 14

 Diseases which accompany CMT
Hip dysplasia (0-20% cases)
Atlanto-occipital anomalies
C1 and C2 bony deformities
Congenital webbing of the neck
Erb Duchenne paralysis
Metatarsus adductus deformity (in-toeing)
Pes equinovarus
Scoliosis 15
 Diagnosing Torticollis
Diagnosis made based on clinical findings

At birth, postnatally

Head-neck ROM examination

Head tilt can be measured using an inclinometer/ goniometer
Tilt from neutral of 1°-15° signifies mild, 16°-30° medium, >30°severe
torticollis
Restriction of cervical rotation on ipsilateral side and lateral flexion on
contralateral side 16
17
 Diagnosing Torticollis

SCM mass / tumour

Question prenatal/perinatal history

Examination of visual fields

Audiological testing

Neurological examination
18
 Radiological Evaluation in CMT
Ultrasonography
Cheap, non invasive, dependable
Look for hyperechogenicity of SCM, measure for difference in SCM
thickness and cross sectional area
Diagnostic sensitivity: 97.9%, specificity: 96.4%
Sonoelastography
Measures displacement of tissue when compressed
Harder tissues become less displaced than softer tissues
19
 Diagnosing Torticollis

Radiographs
Used to evaluate craniofacial and cervical vertebrae anomalies
Anteroposterior and lateral used to rule out cervical vertebral fractures and subluxation

Computerised tomography
Visualisation of craniofacial and cervical vertebrae anomalies

Magnetic resonance imaging

Evaluation of muscular thickening and posterior fossa tumours
Contrast MRI used to rule out cranial tumours 20
 Treatment of CMT

Treatment aims:

Restore head positioning to midline

Obtain a symmetric posture

Prevent/ treat craniofacial asymmetry

Prevent/ treat limited cervical ROM

21
 Points to Remember
CMT can spontaneously resolve

Persistent CMT can result in severe craniofacial asymmetry

Treatment of CMT in new born much easier

Diagnosis and treatment of fibromatosis colli at 3-6 months of age much

more difficult, may require and invasive procedure

Early diagnosis and treatment give quicker and better results

22
 Early Conservative Treatment of CMT
Education
Active positioning of child and head
Neck and shoulder ROM exercises
Passive stretching exercises
Use of orthoses
Kinesiotaping
Manipulative therapy
Botulinum toxin injection

23
 CMT: Family Education
Nature and course of disease, findings, follow up and treatment plan
Importance of correct position during
Breast feeding

Sleeping

In a vehicle, push chair, swing

Importance of implementing a home exercise program

24
Positioning of Child

Support head with pillows to assist a

symmetrical posture

Lie baby on right and left sides

alternately to avoid development of
plagiocephaly

When carrying baby, support the

neck with one hand and head with
the forearm. Place other hand
between legs and support body 25
Positioning of Child
To avoid delay in development
of gross motor function, keep
baby prone when awake

Stimulate baby with light

sources/toys from the affected
side to encourage activity in that
direction

26
 Positioning of Baby

Short and frequent feeding

Feeding in prone position with head extended

27
 Range of Motion Exercises

Slow, controlled neck range of motion exercises in all directions

Repeat 5-15 times daily

Continue exercises for at least 1 year

Exercises performed from <6 months old give good results

28
 Passive Stretching Exercises
Most frequently recommended treatment
Place child supine and stabilize shoulders
Whilst neck is in lateral flexion, aim to touch ear of non-affected side to
ipsilateral shoulder
To bring chin to the shoulder on the affected side, rotate head in the
transverse axis
Whilst neck is extended, perform lateral flexion and rotation stretching
exercises
Hold stretch for 10 seconds, repeat at least 15 times daily
Contraindicated in the presence of cervical vertebra anomaly
29
30
 Patient Follow up

2-4 weeks
Passive cervical ROM
Active cervical vertebra and torso ROM
Passive stretching exercises
Re-education of parent/ carer with social integration plan

31
 Use of Orthoses in CMT
≥ 10 degrees torticollis despite regular exercise in > 4 month old →
tubular torticollis orthosis
Use of cranial orthosis (helmet) in child <1 year old if plagiocephaly
and facial asymmetry present

32
 Kinesiotaping in CMT

A complementary therapy
Positive effects debated
Application x1/week for 5-6
weeks
Difficulties involving
application
33
 Manipulation/ Mobilization in CMT

Myokinetic stretching techniques

Aims to treat the strained muscles and allow for elongation of SCM

Involves placing 5-10 seconds of deep pressure on fibrotic mass to

allow for myofascial relaxation

34
 Botulinum Toxin A in CMT

Used in those who do not benefit from physical therapy and

exercises

Success maybe limited due to fibrotic changes occurring in SCM

35
 Surgery
Indications for surgery
Development of facial asymmetry
No improvement after 6-12 months of conservative treatment
Cervical lateral flexion limited by >15º, rotation >30º
Aims of surgery
Improve cervical ROM
Remediate deformities

1-4 years old surgery involves unipolar release, bipolar release, resection of
muscle
36
 Conclusion
Timely diagnosis and treatment imperative
Early treatment allows for greater treatment success
When planning treatment, evaluation of fibrotic mass, cervical
movement and CMT related deformities are important
Family should be educated re. correct positioning of child, and
treatment plan
Follow up every 2-4 weeks recommended
37
Thank you

38