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Torticollis
King Edward medical
university
Rabia Mustafa
2
Table of Contents
Definition …………………………………..3
Symptoms……………………………………5
Diagnosis ……………………………………6
Classification……………………………….7
Treatment………………………………….8
3
Torticollis
Definition
Torticollis is a symptom related to turning or bending of the neck. Many different
causes are possible. In newborns, Torticollis usually results from injury during labour
and delivery or the infant’s position in the womb. Less often, it is caused by birth
defects. In older children, torticollis may result from injuries to the neck muscles,
common infections, or other causes.
What does it look like?
 Abnormal twisting of the neck. Usually, child’s head is tipped toward one side,
with the chin pointing in the other direction.
 Painful spasms of the neck muscles may occur.
 Other symptoms may be present, depending on the cause.
 For example, there may be a tender lymph node (gland) if the cause is infection.
4
Causes:
Torticollis may be,
 Inherited -- due to changes in your genes
 Acquired -- develops as a result of damage to the nervous system, upper spine,
or muscles
If the condition occurs without a known cause, it is called idiopathic torticollis.
There are many possible causes of torticollis. In most children, the problem is only
temporary or can be managed with simple treatments. Less often, torticollis is a more
serious problem. If child has torticollis or any problem moving his or her neck, it’s
important to get medical evaluation to find out what’s causing the problem. In
newborns, torticollis most often results from causes related to the muscles in the neck
and shoulder area. It may be caused by injuries to the neck muscles during a difficult
delivery. At other times, it’s simply the way the infant was positioned in the womb. Less
commonly, different types of birth defects may cause torticollis in a newborn
In older children, possible causes of torticollis include:
 Injury to the neck muscles. Sometimes the trauma is minor, such as sleeping in an
awkward position. Much less often, the vertebrae in the neck may become
dislocated or fractured because of trauma.
 Infections or inflammation in the neck. The lymph nodes in the neck may become
infected or inflamed, interfering with normal neck motion. Less commonly,
torticollis
 may be caused by a deeper infection such as an abscess
Symptoms:
 limited range of motion of the head
 headache
 head tremor
 Neck pain
 Shoulder that is higher on one side of the body
 Stiffness of the neck muscles
 Swelling of the neck muscles (possibly present at birth)
 The baby’s head may be flattened as a result of remaining in one position - this
may be called ‘plagiocephally’.
5
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 hip and club foot 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 these tests can be used to diagnose the torticollis ,
 Ultrasound scan
 X ray
 Concern with physiotherapist
Classification of torticollis:
There are following main types of torticollis
1. Congenital muscular torticollis
The etiology 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
6
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. 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.
2. Acquired torticollis
No congenital muscular torticollis can result from scarring or disease of cervical
vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal
abscess, or cerebellar tumours. It may be spasmodic (clonic) or permanent (tonic). The
latter type may be due to potts’ disease (tuberculosis of the spine).
 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.
 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 pharynx 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 debridement in intractable
cases.
 Ear infections and surgical removal of the adenoids can cause an entity known as
Grisel's syndrome, a subluxation of the upper cervical joints, mostly the
atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an
7
infection. This bridge must either be broken through manipulation of the neck,
or surgically resected.
 The use of certain drugs, such as antipsychotics, can cause torticollis.
Antiemetics - Neuroleptic Class - Phenothiazines
 There are many other rare causes of torticollis.
3. Spasmodic torticollis
Spasmodic torticollis is the Torticollis with recurrent but transient contraction of the
muscles of the neck and especially of the sternocleidomastoid. Synonyms are
"intermittent torticollis", "cervical dystonia" or "idiopathic cervical dystonia",
depending on cause
There are other different types of torticollis such as,
Temporary torticollis
For most children, torticollis goes away after a day or two. All your child may need is
some rest, and perhaps a towel wrapped around the neck to keep it still. This temporary
problem sometimes happens when your child’s lymph nodes are hot and swollen
(inflamed) after he has had an ear infection or a cold.
Fixed torticollis
Sometimes torticollis is permanent (fixed) because of a problem with muscles or bone
structure. In rare cases, fixed torticollis is caused by an abnormal area in the back part
of the brain, or by a tumor In the spinal cord Torticollis is sometimes caused by eye
muscle imbalance or stomach acids that get into the tube that connects the mouth to the
stomach (esophagus). The faces of some children with fixed torticollis may look
unbalanced or flattened (plagiocephally). Children may also have mild delays in
developing the ability to use their muscles (motor skills).
Muscular torticollis
Muscular torticollis is the most common type of fixed torticollis. It happens when your
child’s neck muscles are especially tight on one side, or if something has caused scarring
on one side of his neck. The tight muscles or scarring can cause your child’s head to tilt
to one side. The etiology of congenital muscular torticollis is unclear. Birth trauma or
intrauterine malposition is considered to be the cause of damage to the
sternocleidomastoid muscles 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. 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
8
symmetry. A TOT Collar is sometimes applied. About 5–10% of cases fail to respond to
stretching and require surgical release of the muscle.
Treatment:
Treatment for torticollis depends on the cause:
 For newborns with torticollis, gentle motion of the head and neck is
recommended to stretch the muscles. Often, a physical therapist is involved. To
avoid injury, this should be done only as recommended by a doctor.
 For older children with torticollis related to infection or inflammation,
treatment may include:
 Antibiotics for the specific infection.
 Rest.
 Anti-inflammatory medications (such as ibuprofen).
 Passive motion to keep the muscles from getting stiff.
 However, the motion should not be painful, and you should never use force to
move the neck.
 If the cause is related to trauma (even sleeping position)
 treatments may include:
 Muscle relaxants such as Valium (generic name: diazepam) Passive motion.
 A soft collar or brace to support the neck.
Complications:
Complications may include:
 Muscle swelling due to constant tension
 Nervous system symptoms due to pressure on nerve roots
Prevention:
Torticollis is usually an unexpected, unpreventable problem. Identifying and treating
the cause may prevent complications related to abnormal movement and positioning of
the neck. While there is no known way to prevent this condition, early treatment may
prevent it from getting worse.
Outlook (prognosis):
The condition may be easier to treat in infants and children. If torticollis becomes
chronic numbness and tingling may develop due to pressure on the nerve roots in the
neck. The muscle itself may become large (hypertrophic) due to constant stimulation
and exercise.

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Torticollis

  • 2. 2 Table of Contents Definition …………………………………..3 Symptoms……………………………………5 Diagnosis ……………………………………6 Classification……………………………….7 Treatment………………………………….8
  • 3. 3 Torticollis Definition Torticollis is a symptom related to turning or bending of the neck. Many different causes are possible. In newborns, Torticollis usually results from injury during labour and delivery or the infant’s position in the womb. Less often, it is caused by birth defects. In older children, torticollis may result from injuries to the neck muscles, common infections, or other causes. What does it look like?  Abnormal twisting of the neck. Usually, child’s head is tipped toward one side, with the chin pointing in the other direction.  Painful spasms of the neck muscles may occur.  Other symptoms may be present, depending on the cause.  For example, there may be a tender lymph node (gland) if the cause is infection.
  • 4. 4 Causes: Torticollis may be,  Inherited -- due to changes in your genes  Acquired -- develops as a result of damage to the nervous system, upper spine, or muscles If the condition occurs without a known cause, it is called idiopathic torticollis. There are many possible causes of torticollis. In most children, the problem is only temporary or can be managed with simple treatments. Less often, torticollis is a more serious problem. If child has torticollis or any problem moving his or her neck, it’s important to get medical evaluation to find out what’s causing the problem. In newborns, torticollis most often results from causes related to the muscles in the neck and shoulder area. It may be caused by injuries to the neck muscles during a difficult delivery. At other times, it’s simply the way the infant was positioned in the womb. Less commonly, different types of birth defects may cause torticollis in a newborn In older children, possible causes of torticollis include:  Injury to the neck muscles. Sometimes the trauma is minor, such as sleeping in an awkward position. Much less often, the vertebrae in the neck may become dislocated or fractured because of trauma.  Infections or inflammation in the neck. The lymph nodes in the neck may become infected or inflamed, interfering with normal neck motion. Less commonly, torticollis  may be caused by a deeper infection such as an abscess Symptoms:  limited range of motion of the head  headache  head tremor  Neck pain  Shoulder that is higher on one side of the body  Stiffness of the neck muscles  Swelling of the neck muscles (possibly present at birth)  The baby’s head may be flattened as a result of remaining in one position - this may be called ‘plagiocephally’.
  • 5. 5 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 hip and club foot 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 these tests can be used to diagnose the torticollis ,  Ultrasound scan  X ray  Concern with physiotherapist Classification of torticollis: There are following main types of torticollis 1. Congenital muscular torticollis The etiology 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
  • 6. 6 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. 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. 2. Acquired torticollis No congenital muscular torticollis can result from scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumours. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to potts’ disease (tuberculosis of the spine).  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.  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 pharynx 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 debridement in intractable cases.  Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an
  • 7. 7 infection. This bridge must either be broken through manipulation of the neck, or surgically resected.  The use of certain drugs, such as antipsychotics, can cause torticollis. Antiemetics - Neuroleptic Class - Phenothiazines  There are many other rare causes of torticollis. 3. Spasmodic torticollis Spasmodic torticollis is the Torticollis with recurrent but transient contraction of the muscles of the neck and especially of the sternocleidomastoid. Synonyms are "intermittent torticollis", "cervical dystonia" or "idiopathic cervical dystonia", depending on cause There are other different types of torticollis such as, Temporary torticollis For most children, torticollis goes away after a day or two. All your child may need is some rest, and perhaps a towel wrapped around the neck to keep it still. This temporary problem sometimes happens when your child’s lymph nodes are hot and swollen (inflamed) after he has had an ear infection or a cold. Fixed torticollis Sometimes torticollis is permanent (fixed) because of a problem with muscles or bone structure. In rare cases, fixed torticollis is caused by an abnormal area in the back part of the brain, or by a tumor In the spinal cord Torticollis is sometimes caused by eye muscle imbalance or stomach acids that get into the tube that connects the mouth to the stomach (esophagus). The faces of some children with fixed torticollis may look unbalanced or flattened (plagiocephally). Children may also have mild delays in developing the ability to use their muscles (motor skills). Muscular torticollis Muscular torticollis is the most common type of fixed torticollis. It happens when your child’s neck muscles are especially tight on one side, or if something has caused scarring on one side of his neck. The tight muscles or scarring can cause your child’s head to tilt to one side. The etiology of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscles 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. 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
  • 8. 8 symmetry. A TOT Collar is sometimes applied. About 5–10% of cases fail to respond to stretching and require surgical release of the muscle. Treatment: Treatment for torticollis depends on the cause:  For newborns with torticollis, gentle motion of the head and neck is recommended to stretch the muscles. Often, a physical therapist is involved. To avoid injury, this should be done only as recommended by a doctor.  For older children with torticollis related to infection or inflammation, treatment may include:  Antibiotics for the specific infection.  Rest.  Anti-inflammatory medications (such as ibuprofen).  Passive motion to keep the muscles from getting stiff.  However, the motion should not be painful, and you should never use force to move the neck.  If the cause is related to trauma (even sleeping position)  treatments may include:  Muscle relaxants such as Valium (generic name: diazepam) Passive motion.  A soft collar or brace to support the neck. Complications: Complications may include:  Muscle swelling due to constant tension  Nervous system symptoms due to pressure on nerve roots Prevention: Torticollis is usually an unexpected, unpreventable problem. Identifying and treating the cause may prevent complications related to abnormal movement and positioning of the neck. While there is no known way to prevent this condition, early treatment may prevent it from getting worse. Outlook (prognosis): The condition may be easier to treat in infants and children. If torticollis becomes chronic numbness and tingling may develop due to pressure on the nerve roots in the neck. The muscle itself may become large (hypertrophic) due to constant stimulation and exercise.