Torticollis

Aim

To guide medical staff with the assessment and management of torticollis.

Risk

Failure to follow this guideline may result in misdiagnosis and suboptimal treatment of torticollis.

Key points

• The term torticollis (or wry neck), from the Latin for ‘twisted neck’, refers to a characteristic position where the head is held tipped to one side with the chin rotated toward the other.
• It is a physical sign, not a condition, and can be caused by a wide range of problems.

Torticollis categories 

1. Torticollis present at birth or neonatal period

Muscular torticollis

• Due to fibrosis and shortening of one of the sternocleidomastoid muscles, secondary to either abnormal intrauterine positioning of the head or birth trauma.
• In birth trauma, bleeding into the body of the muscle causes a mass which can be seen and felt (known as “sternocleidomastoid tumour of infancy” or “fibromatosis colli”) which undergoes fibrosis and shortening, resulting in the typical head position.
• Treatment usually involves physiotherapy with gentle passive stretching exercises and positioning of the baby in their cot to encourage looking toward the affected side.
• Rarely surgical release is necessary to prevent secondary plagiocephaly.

Positional torticollis

• Postural torticollis occurs when the infant favours turning to one side. There is usually no sternomastoid tightness and full passive range of movement. Usually responds to encouraging baby to turn the opposite side.

Congenital vertebral abnormalities

• In cases where birth trauma was unlikely and no sternomastoid mass can be felt, cervical spine X-rays (AP and lateral) should be done to look for bony abnormalities before any manipulation is done.

2. Torticollis in a previously unaffected child

• Most cases are benign caused by minor muscle trauma, or inflammation and spasm secondary to a nearby inflammatory process.
• Trauma may have been so minor that a particular event may not be recalled.  More significant trauma may result in subluxation, dislocation or fracture of cervical vertebrae, or fracture of a clavicle.
• If history of significant trauma, immobilise in C-spine hard collar and refer to cervical spine trauma.
• Any inflammatory process in the area can cause torticollis, including upper respiratory tract infection, cervical lymphadenitis, dental abscess, retropharyngeal abscess, or upper lobe pneumonia.
• Dystonic drug reactions may sometimes present as torticollis.
• An uncommon, but serious cause of torticollis is a tumour of the posterior fossa or spinal cord – perform a full neurological examination.

Assessment

Investigations

• If infective or inflammatory cause thought to be unlikely or if their is a history of trauma, cervical spine X-Rays should be taken.
• A full neurological examination including ophthalmological examination should be performed.

Management

• Muscular torticollis in infants can be managed with physiotherapy. These infants should be referred on to Child Development Services for physiotherapy input or to private paediatric physiotherapy.
• Where minor trauma or muscular spasm is thought to be the cause, the patient can be treated symptomatically (analgesic and anti-inflammatory –  e.g. Ibuprofen) and followed up by GP. A referral to a physiotherapist should also be considered. 
• Infection should be treated with appropriate antibiotics if thought to be bacterial +/- referral to specialist team (e.g. ENT).
• If no cause found, treat symptomatically, but will require GP follow up.

Bibliography

1. Acquired torticollis in children Charles G Macias, MD, MPHVanthaya Gan, MD. Accessed at www.uptodate.com
2. Torticollis.Tomczak KK, Rosman NP J Child Neurol. 2013 Mar;28(3):365-78. Epub 2012 Dec 26. 
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 

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