Torticollis

TorticollisTorticollis, or wryneck, includes a variety of conditions that require different management.

Acute Torticollis

Acute torticollis is relatively common. It may occur spontaneously, follow minimal trauma, or occur after an upper respiratory infection. Why the head tilts is uncertain. The tilt may be due to muscle spasm secondary to cervical lymphadenitis or possibly due to a minor subluxation of the cervical vertebrae.

Clinical features Acute torticollis causes the head to tilt, rotate to one side and become fixed. Radiographs of the cervical spine are difficult to assess because of the lateral flexion and rotation. Laboratory studies are normal.

Manage by immobilizing the neck with a folded towel and encourage rest. Early management is usually provided by the primary care physician. In most children, acute torticollis resolves within 24 hours. If the deformity persists longer than 24–48 hours, be more concerned and manage as rotatory displacement.

Rotatory Displacement

The more severe form of acute torticollis is called rotatory displacement or rotatory subluxation. This may be associated with severe pharangitis or otitis media, or follow head and neck surgery or trauma; in some cases, it occurs spontaneously. Treat rotatory displacement early to avoid permanent fixation and residual deformity.

Evaluate Determine the duration of the deformity and any associated history such as trauma or infections. Sometimes torticollis follows head or neck surgery. Patients with Marfan syndrome are susceptible. Examine the child for localized tenderness and neck range of motion. Perform a careful neurological examination. Be aware that spinal cord tumors may present with torticollis. Perform appropriate laboratory studies if infection is suspected. The value and reliability of conventional and dynamic CT scans are controversial and probably have little value in planning management.

Manage First apply traction. If early, head-halter traction is appropriate. In most children, the torticollis resolves with traction. If the deformity has persisted more than a week before resolution, consider extending the period of immobilization for 2 or 3 months using a Minerva cast. For persisting deformity, halo traction or manipulation under anesthesia may be necessary. Should all these measures fail, operative repositioning and C1–C2 fusion may be necessary.

Chronic Nonmuscular Torticollis

In about 20% of children with chronic torticollis, it is due to nonmuscular causes. Radiographs may show conditions such as Klippel-Feil anomaly or hemivertebrae. If radiographs are negative and the sternocleidomastoid muscle is not contracted, consider an ocular etiology. Refer to an ophthalmologist for evaluation. Consider the other conditions that may cause torticollis, such as neonatal brachial plexus palsies and spinal cord tumors, before starting treatment.

Muscular Torticollis

Muscular torticollis is relatively common and presents in two age groups.

Infantile muscular torticollis The infant is first seen because of a head tilt. Sometimes a history of a breech delivery is given and a firm tumor of the sternocleidomastoid muscle is palpated. Usually only a head tilt and limited neck motion due to a contracture of the muscle are found. Plagiocephaly (asymmetrical head) may be present.

Be certain to rule out developmental hip dysplasia. Even if the hip examination is negative, evaluate the hip by either ultrasound if the infant is seen in the neonatal period or by a single AP radiograph of the pelvis if the infant is older than about 10 weeks of age.

Infantile torticollis resolves spontaneously in about 90% of cases. The value of physical therapy by stretching is uncertain. Of those that persist, operative correction may be necessary. Delay correction until about 3 years of age. Plagiocephaly rarely persists and is a cosmetic problem.

Juvenile muscular torticollis Sometimes muscular torticollis appears to develop during childhood. In this juvenile type, usually both heads of the muscles are contracted, causing the head tilt and limiting neck motion. This type of torticollis usually is permanent and often requires operative correction.

Operative correction Bipolar release is the most effective procedure for correction of both infantile and juvenile forms of muscular torticollis.

Bipolar Release for Muscular Torticollis

Most cases of muscular torticollis resolve during infancy. If the deformity persists into childhood and poses a cosmetic disability, release is indicated. Bipolar release of the contracted sternocleidomastoid muscle is usually appropriate, as double-level release provides better correction with less risk of recurrence. Endoscopic releases have been recommended; however, the open release can be performed through small skin line incisions, which provide equivalent cosmetic results.

Preoperative Planning Make certain the diagnosis is muscular torticollis. Note the location of the contractures. This boy shows the typical deformity with the clavicular head (red arrow) more contracted than the sternal head (blue arrow). If the deformity is severe, both distal heads should be released. If the deformity is moderate and if leaving the contour is considered important, the sternal head may be left intact.

Technique Position the child with a towel under the upper chest to allow extension of the head to make the contracture prominent during the release. Avoid nerves and vessels during the release procedure. Although the array of these structures may seem worrisome, they can easily be avoided. The facial nerve lies well anterior, and the auricular artery and nerve can be avoided by careful isolation of each segment of scar before excision. The accessory nerve lies distant, midway between the incisions. Distally, the vein and nerve lie deep to the fascia. The strands of fibrotic scar are distributed randomly within the muscle. Perform the proximal release first. Make a small transverse incision over the proximal portion of the muscle. With the muscle under tension, identify the fibrotic strands and divide each. Make certain that the release is complete. Make the second short transverse skin line incision in the skin crease well above the clavicle. The mobile skin allows an extensive excision through a small incision. Release the muscle, fibrous tissue, and investing fascia. Close only the skin with subcuticular sutures. Reinforce the closure with paper tape. Apply a bulky dressing. Once the child is awake, a slightly compressive overdressing may be applied.

After Care The child may be discharged the next day. Gentle stretching may be started within a few days. If the deformity is severe, apply a fiberglass jacket that includes the head (Minerva cast). Position the head in slight overcorrection in the cast. Cut windows for the face and ears. This cast may be applied in the clinic several days following discharge and should be worn for about 6 weeks. At cast removal, the incisions will be well healed. At 3 months after surgery, the scars and the head tilt are acceptable. This position is much better than the preoperative head tilt.

Complications are uncommon.

Residual head tilt is usually due to incomplete release or lack of postoperative range of motion or immobilization.

Bad scars may be due to excessive length, non-skin-line orientation, noncosmetic closure, or keloid formation.

Neurovascular damage can be avoided by careful technique.

Recurrence is uncommon and its cause may be uncertain.

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