186 S. Jones

that varies according to the etiology. This chapter will define the two types of torticollis and discuss the evaluation and treatment of both.

19.2  Etiology and Types of Torticollis

1.Congenital muscular torticollis (CMT): The etiology is controversial with proposed causative factors being birth trauma, an ischemic event, venous occlusion, intrauterine malposition, genetic factors, constitutional growth arrest, infective myositis, neurogenesis, and intrauterine compartment syndrome.

a.CMT is divided into three groups, the most common being Group 1 – the sternocleidomastoid tumor (SMT). This consists of torticollis and a palpable SCM tumor, called fibromatosis colli, which is palpable in the body of the SCM and present at birth. Group 2, or muscular torticollis (MT) is torticollis with a tightness of the SCM, but no palpable tumor. Group 3, or POST (postural torticollis) has no mass or tightness of the SCM. The usual age of presentation is 2–4 months of age, with SMT presenting earliest and POST presenting later.

b.Evaluation begins with physical exam showing the head tilted toward the shortened SCM and the chin rotated opposite. If a palpable tumor is not present in SCM, ultrasound or MRI may be used to identify a fibrotic lesion in the SCM and to differentiate from other pathologies in the neck. Any bony abnormalities seen on radiographs is a contraindication to manual therapy.

2.Acquired or non-muscular torticollis (NMT): Torticollis described from as many as 80 different etiologies resulting in the characteristic head and neck tilt. In a retrospective study of 288 patients with confirmed torticollis, the incidence of NMT was 18.4% of all cases of torticollis. NMT was subdivided into the following categories:

a.Klippel-Feil and congenital scoliosis – 5.6% of all torticollis, 30.2% of all non-muscular causes

b.Ocular disorders – 4.2%, 22.6% respectively

c.Central nervous system abnormalities (posterior fossa and cervical spine tumors, syringomyelia or Arnold-Chiari malformation) – 2.1%, 11.3%

d.Obstetrical palsies – 3.1%, 17%

e.Clavical fractures – 0.7%, 3.8%

f.C1-C2 rotary subluxations – 0.7%, 3.1%

g.Inflammatory conditions – 0.7%, 3.1%

h.Idiopathic or unexplained – 1.4%, 7.6%

3.Work-up of non-muscular causes of torticollis can be performed based on the algorithm described by Ballock et al. (Fig. 19.1). After a history and physical exam excludes CMT, based on a palpable mass of the SCM and early age of presentation, inflammatory causes or birth trauma are ruled out. Cervical and bony radiographs define any bony abnormalities. An eye exam defines abnormalities causing ocular torticollis. A neurologic examination, possibly including a MRI, identifies CNS or spinal cord abnormalities. Finally, pain indicates the need for evaluation of an osteoma or osteoblastoma. If CMT or the above causes of torticollis are ruled out, observation and physical therapy are indicated.

19.3  Treatment of Torticollis

1.Positioning and handling of infant should encourage infant to rotate head toward affected side during feeding or crib placement.

2.Manual stretching – best outcome is achieved when conducted by a trained physiotherapist. First line of therapy for initial treatment or for mild cases. May incur a snapping sound that is thought to be tearing of the SCM body or fibrotic band. No studies have shown adverse outcomes when such a sound is heard during therapy.

3.Orthotics – tubular orthosis for torticollis (TOT) collar – used in conjunction with physiotherapy or after surgery. This soft collar is best used for children around 4–6 months of age.

4.Surgical therapy – definitive therapy of refractory­torticollis. Surgeon preference dictates surgery performed, as no studies have proven benefit of one type of operation over another. Surgical options include simple myotomy, unior bipolar release of the SCM, z-plasty or myoplasty, subperiosteal lengthening of the SCM at its origin and insertion, or resection of the SCM itself.

5.Non-conventional therapy – botox injection – not well tested or commonly used.

19.4  Indications for Referral

1.Most CMT will resolve 2–6 months of age. If it persists, referral to a physiotherapist is indicated.

2.If NMT is suspected, the underlying etiology should be investigated.

3.If deficit of passive rotation >10°, refer to physiotherapist for manual stretching.

4.If patient has significant head tilt and deficits of passive rotation and side flexion >10°–15°, the presence of a tight band or mass in the SCM, has not responded to 6 months of physiotherapy manual stretching, refer to a surgeon for surgical treatment.

Suggested Readings

1.Do TT. Congenital muscular torticollis: Current concepts and review of treatment. Curr Opin Pediatr. 2006;18:26-29.

2.Tang SP, Cheng J. Outcome of surgical treatment of congenital muscular torticollis. Clin Orthop Relat Res. 1999;362:190-200.

3.Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop. 1996;16(4):500-504.

4.Cheng JC, Tang SP, Chen TM, Wong MN, Wong EM. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants – a study in 1086 cases. J Pediatr Surg. 2000;35: 1091-1096.

5.Canale ST, Griffin DW, Hubbard CN. Congenital muscular torticollis. A long-term follow-up. J Bone Joint Surg. 1982;64:810-816.

190 S. Jones

6.Ohman A, Nilsson S, Lagerkvist AL, Beckung E. Are infants with torticollis at risk of a delay in early motor milestones compared with a control group of healthy infants? Dev Med Child Neurol. 2009;51:545-550.

7.Chen JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. J Bone Joint Surg. 2001;83A(5):679-687.

8.Rogers GF, Oh AK, Mulliken JB. The role of congenital muscular torticollis in the development of deformational plagiocephaly. Plast Reconstr Surg. 2009;123:643-652.

9.Lin JN, Chou ML. Ultrasonographic study of the sternocleidomastoid muscle in the management of congenital muscular torticollis. J Pediatr Surg. 1997;32(11):1648-1651.

10.Rosman NP, Douglass LM, Sharif UM, Paolini J. The neurology of benign paroxysmal torticollis of infancy: Report of 10 new cases and review of the literature. J Child Neurol. 2009;24(2):155-160.

11.Mezue WC, Taha ZM, Bashir EM. Fever and acquired torticollis in hospitalized children. J Laryngol Otol. 2002;116:280-284.

12.Koumanidis S, Per H, Gismos H, et al. Torticollis secondary to posterior fossa and cervical spinal cord tumors: report of five cases and literature review. Neurosurg Rev. 2006;29:333-338.