Torticollis
Encyclopedia
Torticollis, or wryneck, is a stiff neck associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature (a condition in which the head is tilted to one side). The muscles affected are principally those supplied by the spinal accessory nerve.
of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle
in the neck. This results in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its range of motion in both rotation and lateral bending. The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side.
Noncongenital muscular torticollis can result from scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine).
The reported incidence of congenital torticollis is 0.3-2.0 %. Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle at the age of two to four weeks. Gradually it disappears, usually by the age of eight months, but the muscle is left fibrotic.
Initially, the condition is treated with physical therapies, such as stretching to release tightness, strengthening exercises to improve muscular balance, and handling to stimulate symmetry. A TOT Collar is sometimes applied. About 5–10% of cases fail to respond to stretching and require surgical release of the muscle.
Infants with torticollis have a higher risk of plagiocephaly
. Altering the head position and using a pillow when supine and frequently lying prone when awake help reduce the risk.
Uncommon causes such as tumors, infections, ophthalmologic problems and any other abnormalities should be ruled out before treatment begins Ocular torticollis due to cranial nerve IV palsy, for one, should not be treated with physical therapy. In that case, the torticollis is a neurological adaptation to maintain binocularity. Treatment should instead aim to improve extraocular muscle imbalance.
If torticollis is not corrected, facial asymmetry often develops. Head position needs to be corrected before about the age of 18 for there to be improvement. Younger children show the best results.
Congenital torticollis manifests in infancy but may not be diagnosed until childhood or even adulthood.
The word torticollis means wry neck: Acquired torticollis is not the same as congenital torticollis and may develop at any age.
Common treatments might involve a multi-phase process:
†An Osteopathic Physician (D.O.) may choose to use Cranial techniques to properly position the occipital condyles - thereby relieving compression of cranial nerve XI in children with Torticollis. This is an example of Osteopathic Manipulative Treatment
.
TREATMENT: Botulinum toxin has been used to inhibit the spastic contractions of the affected muscles.
and clubfoot should be examined. Radiographs of the cervical spine should be obtained to rule out obvious bony abnormality, and MRI should be considered if there is concern about structural problems or other conditions.
Evaluation by an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems (IV cranial nerve
palsy
, nystagmus-associated "null position," etc.). Most cases in infants respond well to physical therapy. Other causes should be treated as noted above.
but sometimes as a result of an injury
. It is seen largely in domestic
rodent
s and rabbit
s, but may also appear in dog
s and other animal
s.
Congenital muscular torticollis
The etiologyEtiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle
Sternocleidomastoid muscle
In human anatomy, the sternocleidomastoid muscle , also known as sternomastoid and commonly abbreviated as SCM, is a paired muscle in the superficial layers of the anterior portion of the neck...
in the neck. This results in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its range of motion in both rotation and lateral bending. The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side.
Noncongenital muscular torticollis can result from scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine).
The reported incidence of congenital torticollis is 0.3-2.0 %. Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle at the age of two to four weeks. Gradually it disappears, usually by the age of eight months, but the muscle is left fibrotic.
Initially, the condition is treated with physical therapies, such as stretching to release tightness, strengthening exercises to improve muscular balance, and handling to stimulate symmetry. A TOT Collar is sometimes applied. About 5–10% of cases fail to respond to stretching and require surgical release of the muscle.
Infants with torticollis have a higher risk of plagiocephaly
Plagiocephaly
Plagiocephaly is a condition characterized by an asymmetrical distortion of the skull.-Causes:It is a common finding at birth and may be the result of a restrictive intrauterine environment. If there is premature union of skull bones, this is more properly called craniosynostosis...
. Altering the head position and using a pillow when supine and frequently lying prone when awake help reduce the risk.
Uncommon causes such as tumors, infections, ophthalmologic problems and any other abnormalities should be ruled out before treatment begins Ocular torticollis due to cranial nerve IV palsy, for one, should not be treated with physical therapy. In that case, the torticollis is a neurological adaptation to maintain binocularity. Treatment should instead aim to improve extraocular muscle imbalance.
If torticollis is not corrected, facial asymmetry often develops. Head position needs to be corrected before about the age of 18 for there to be improvement. Younger children show the best results.
Congenital torticollis manifests in infancy but may not be diagnosed until childhood or even adulthood.
The word torticollis means wry neck: Acquired torticollis is not the same as congenital torticollis and may develop at any age.
Common treatments might involve a multi-phase process:
- Low-impact exercise to increase strong form neck stability
- Manipulation of the neck by a chiropractor, physical therapist, or D.O.†
- Extended heat application.
- Repetitive shiatsu massage.
†An Osteopathic Physician (D.O.) may choose to use Cranial techniques to properly position the occipital condyles - thereby relieving compression of cranial nerve XI in children with Torticollis. This is an example of Osteopathic Manipulative Treatment
Osteopathic Manipulative Medicine
Osteopathic Manipulative Medicine is the application of the distinct osteopathic philosophy, structural diagnosis and use of Osteopathic Manipulative Technique in the diagnosis and management of the patient. OMM takes into account the physical and mental health of a patient, and how either aspect...
.
Acquired torticollis
Acquired torticollis occurs because of another problem and usually presents in previously normal children and adults.- A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common ('stiff neck') and will pass spontaneously in 1–4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds or unusual postures are implicated; however in many cases no clear cause is found. These episodes are rarely seen by doctors other than a family physician.
- Trauma to the neck can cause atlantoaxial rotatory subluxationSubluxationA subluxation may have different meanings, depending on the medical specialty involved. It implies the presence of an incomplete or partial dislocation of a joint or organ. The World Health Organization defines both the medical subluxation and the chiropractic subluxation...
, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. - Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically.
- Infections in the posterior pharynxPharynxThe human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...
can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridementDebridementDebridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...
in intractable cases. - Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndromeGrisel's syndromeGrisel’s syndrome is a non-traumatic subluxation of the atlanto-axial joint caused by inflammation of the adjacent tissues.-References:* Grisel P. Enucléation de l’atlas et torticollis naso-pharyngien. Presse Med 1930;38:50–4....
, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or surgically resected. - The use of certain drugs, such as antipsychoticAntipsychoticAn antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
s, can cause torticollis. - Antiemetics - Neuroleptic Class - Phenothiazines
- There are many other rare causes of torticollis.
Spasmodic torticollis
Torticollis with recurrent but transient contraction of the muscles of the neck and esp. of the sternocleidomastoid. "intermittent torticollis . "cervical dystonia"TREATMENT: Botulinum toxin has been used to inhibit the spastic contractions of the affected muscles.
Diagnosis
Evaluation of a child with torticollis begins with history taking to determine circumstances surrounding birth and any possibility of trauma or associated symptoms. Physical examination reveals decreased rotation and bending to the side opposite from the affected muscle. Some say that congenital cases more often involve the right side, but there is not complete agreement about this in published studies. Evaluation should include a thorough neurologic examination, and the possibility of associated conditions such as developmental dysplasia of the hipHip dysplasia (human)
Hip dysplasia, developmental dysplasia of the hip or congenital dysplasia of the hip is a congenital or acquired deformation or misalignment of the hip joint.-Terminology:...
and clubfoot should be examined. Radiographs of the cervical spine should be obtained to rule out obvious bony abnormality, and MRI should be considered if there is concern about structural problems or other conditions.
Evaluation by an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems (IV cranial nerve
Trochlear nerve
The trochlear nerve is a motor nerve that innervates a single muscle: the superior oblique muscle of the eye....
palsy
Palsy
In medicine, palsy is the paralysis of a body part, often accompanied by loss of sensation and by uncontrolled body movements, such as shaking. Medical conditions involving palsy include cerebral palsy , brachial palsy , and Bell's palsy ....
, nystagmus-associated "null position," etc.). Most cases in infants respond well to physical therapy. Other causes should be treated as noted above.
In animals
The condition can also occur in animals, usually as a result of an inner ear infectionLabyrinthitis
Labyrinthitis is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house the vestibular system . Labyrinthitis can cause balance disorders....
but sometimes as a result of an injury
Injury
-By cause:*Traumatic injury, a body wound or shock produced by sudden physical injury, as from violence or accident*Other injuries from external physical causes, such as radiation injury, burn injury or frostbite*Injury from infection...
. It is seen largely in domestic
Domestication
Domestication or taming is the process whereby a population of animals or plants, through a process of selection, becomes accustomed to human provision and control. In the Convention on Biological Diversity a domesticated species is defined as a 'species in which the evolutionary process has been...
rodent
Rodent
Rodentia is an order of mammals also known as rodents, characterised by two continuously growing incisors in the upper and lower jaws which must be kept short by gnawing....
s and rabbit
Rabbit
Rabbits are small mammals in the family Leporidae of the order Lagomorpha, found in several parts of the world...
s, but may also appear in dog
Dog
The domestic dog is a domesticated form of the gray wolf, a member of the Canidae family of the order Carnivora. The term is used for both feral and pet varieties. The dog may have been the first animal to be domesticated, and has been the most widely kept working, hunting, and companion animal in...
s and other animal
Animal
Animals are a major group of multicellular, eukaryotic organisms of the kingdom Animalia or Metazoa. Their body plan eventually becomes fixed as they develop, although some undergo a process of metamorphosis later on in their life. Most animals are motile, meaning they can move spontaneously and...
s.