Torticollis, general

• spasmodic, unilateral contraction of neck muscles
• due to birth trauma or in utero position
• may be associated with other orthopedic or neurologic anomalies
• in older kidz; if torticollis vanishes when patient's eyes are covered, or when changing from sitting to supine, ocular torticollis is likely (EOM imbalance) vs orthopedic torticollis (SCM muscle imbalance)
• #1 cause of torticollis in childhood: fibrous dysplasia of the sternocleidomastoid

Exam

• Not usually seen in nbn period, but hematoma may be palpated after birth
• firm, immobile, fibrous mass olive-sized mass or tightness in mid-SCM (usually on R side) at 2 weeks of age, reaches maximal size @ 1 m/o, disappears by 4-6 mos; 
• In relation to the affected side: will see head turned toward, chin rotated away
• there may be slight facial assymetry
• Examine the back for scapular size and mobility, since there is an association of torticollis with Sprengel’s deformity.

Histologically: dense fibrous tissue; may represent prenatal venous obstruction and muscle damage to SCM

Differential Dx and workup

• Klippel-Feil
• Other conditions that usually occur later in childhood:
  • inflammatory/infectious conditions of head/neck/OP
  • traumatic C-spine injury
  • atlantoaxial rotay subluxation.
• Consider other etiologies, e.g.,hemivertebrae, eye problems
• 8-20% association of congenital muscular torticollis with  DDH, so focus on hip exam and consider a hip ultrasound or XR depending on age of child

Treatment for congenital torticollis

1. passive stretching exercises by extending the neck and head over a table or mother’s knee approximately 20 times, three times daily.
2. positioning child's crib so that external stimuli cause child to turn head and neck away from the side of the deformity.
3. If the problem does not resolve by age 6-12 months, the patient should be referred to Ortho.
4. The deformity must be corrected before the ocular righting reflex is developed, between ages 5 to 6, or the child may not be able to maintain the correction because holding the head level may interfere with vision.

CHLA Board Review 2005