Torticollis

Key Points

• Torticollis may be congenital or acquired.

• Congenital torticollis may be characterized by a palpable tumor in the sternomastoid muscle in some cases.

• Acquired torticollis may be caused by a spinal tumor.

• Traumatic injury and retropharyngeal abscess require emergency treatment.

• Management of acquired torticollis includes treating the underlying cause.

Torticollis, also called wry neck, is characterized by contraction of the sternomastoid muscle on one side of the neck, in which the head is tilted to the same side as the contracted muscle, and the chin is rotated to the opposite side. The condition may be congenital or acquired.

Congenital torticollis is caused by the contraction of the sternomastoid muscle. The cause is unclear but may be associated with birth trauma or an abnormal fetal uterine position causing local muscle ischemia. Children with hip dysplasia and breech delivery have a higher incidence of torticollis. Also, delayed development of the face on the affected side may result in facial asymmetry and changes in the cervical vertebrae. On examination, a small lump may be palpable in the muscle, known as a sternomastoid tumor.

In mild cases, treatment is initiated early and includes gentle stretching exercises several times daily. Supervised physical therapy may be considered. Surgery may be considered in special circumstances with patients who do not respond to conservative treatment. The procedure includes surgical release of the sternomastoid muscle, followed by corrective exercises.

Acquired torticollis usually does not involve contraction of the sternomastoid on the same side of the neck. The torticollis has a particular cause, such as upper respiratory tract infections, cervical lymphadenitis, trauma minor neck injury, unilateral subluxation of the vertebrae, or fractures, as well as unusual causes such as spinal tumor or retropharyn-geal abscess. Torticollis may also be seen in relation to ocular disturbance, such as strabismus, known as ocular torticollis.

History includes duration and onset of symptoms, whether sudden or gradual, associated symptoms (e.g., fever, sore throat), and history of injury. Clinical examination, in addition to the clinical appearance of torticollis, requires careful general examination of the head and neck, looking for a cause. Diagnosis may be apparent from the history and physical examination. Radiographs of the cervical spine may be obtained, if indicated, to rule out a vertebral cause.

Management includes referral for emergency evaluation and treatment of traumatic injury and retropharyngeal abscess. Pain is relieved and the underlying cause treated. Persistent pain requires further evaluation.

KEY TREATMENT

Treatment of congenital torticollis includes gentle stretching exercises; surgical treatment may be considered in special circumstances (Do, 2006) (SOR: C).

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