1.
Torticollis
DR/ MAHMOUD SALAMA
2016
QENA FEVER, GIT AND HEPATOLOGY HOSPITAL

2.
Introduction: What is Torticollis?
• Derived from the
Latin: tortus
(twisted) + collis
(neck or collar)
• Torticollis is a
symptom related
to turning or
bending of the
neck.

3.
Introduction
• Many different causes are possible.
• In newborns, Torticollis usually results from
injury during labour and delivery or the
infant’s position in the utreus. 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.

4.
Introduction
• Torticollis refers to a symptom rather than a
distinct disease process
• It can be caused by a wide variety of
conditions (over 80 causes have been
described) which range from relatively simple
self limited to life-threatening
• May be congenital or acquired
• Occurs more frequently in children than in
adults
• The right side is affected in 75% of patients

5.
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.

6.
Causes of Torticollis

7.
1. Congenital muscular torticollis
2. Acquired torticollis

8.
Congenital muscular torticollis (CMT)
• CMT refers to muscular disorders causing
torticollis at birth or shortly after due to
unilateral shortening of the
sternocleidomastoid muscle.
• More common in males and on the right side.
• The affected muscle develops fibrotic changes
which can be associated with a mass
(fibromatosis colli) or without a mass

9.
Congenital muscular torticollis
• Presentation is usually during the first 4
weeks of life with torticollis and / or
nontender neck mass.
• Thought to be caused by intrauterine
and perinatal events. Risk factors for CMT
include overcrowding environments
,first-born, oligohydramnios, breech
presentation and difficult delivery.

10.
Congenital muscular torticollis
Ultrasound (US) is the imaging modality of
choice for initial investigation.
• There is diffuse or focal enlargement of the
sternocleidomastoid muscle.
• Focal mass is usually hypoechoic and
homogenous (fig 3).
• The mass usually resolve within the first year
of life with conservative treatment.

11.
Congenital muscular torticollis
• 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 Collar is sometimes applied.
• About 5–10% of cases fail to respond to
stretching and require surgical release of the
muscle.

12.
2- Acquired torticollis

13.
Acquired torticollis
the most common etiologies
1. self-limiting
2. Trauma,
3. infections
4. inflammatory conditions,
5. central nervous system tumors or lesions

14.
1- self-limiting
• 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.
• colds or unusual postures are implicated;
however in many cases no clear cause is
found.

15.
2- Trauma
• Occipital condyle fracture and facet dislocation
may present with torticollis
• Atlanto-axial rotatory fixation (AARF) of C2
• Spontaneous spinal epidural hematoma is a
rare disorder which might manifest with painful
torticollis followed by weakness and sensory
loss and is mostly common at the cervico-
thoracic level
• Subarachnoid hemorrhage

16.
Trauma
• CT is the modality of choice in most
trauma cases.
• MRI is indicated in any case of
concern for ligamentous injury or
when there is a neurologic deficit.

17.
3- Infection and inflammation
• Head and neck and spinal column
infections may cause torticollis either
by muscular or ligamentous irritation
or from direct spinal disease.

18.
Infectious and Inflammatory Causes of
Torticollis
• CNS related
– Meningitis
• Head and Neck related
– Upper respiratory infections
– Otitis media
– Mastoiditis/Bezold’s abscess
– Cervical adenitis
– Retropharyngeal abscess
• Spine related
– Vertebral osteomyelitis and/or discitis
– Epidural abscess
– Rheumatoid arthritis

19.
Infection
• Lateral neck X RAY radiograph will show
increased soft tissue thickness anterior to the
C spine in retropharyngeal abscess
• US may show superficial lymphadenitis and
abscess.
• CT is used to visualize the deep neck spaces
and for pre-surgical planning.
• MRI is useful in spinal column infections due
to its increased sensitivity and its ability to
show soft tissue and epidural extension

20.
Infectious Causes of Torticollis:
Mastoiditis/Bezold’s Abscess

21.
4- Tumors
• Tumors of the CNS, spine and neck may cause
torticollis
• • CNS tumors are usually in the posterior fossa
or C spine.
• The common presentation of C spine tumor is
pain due to dural irritation.
• Posterior fossa tumors ( CERBELLAR tumor)
may also have signs of increased intracranial
pressure.

22.
4- Tumors
• In any case of insidious development
of torticollis the possibility of a
tumor should be considered.
• MRI is the imaging modality of
choice

23.
Other causes
• The use of certain drugs, such as
antipsychotics , Antiemetics ,
Neuroleptic Class and
Phenothiazines , can cause torticollis.

24.
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.

25.
• 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.
• Surgery if indicated

26.
• If the cause is related to trauma
(even sleeping position) treatments
may include:
• Muscle relaxants - Valium (generic
name: diazepam) and Passive
motion.
• A soft collar or brace to support the
neck.

27.
Conclusion
• Torticollis is a clinical sign that might signify
an underlying disorder.
• In newborn infants with CMT, ultrasound is
preferred and often diagnostic.
• In older children CT is used to diagnose
traumatic insult, neck infection and vertebral
anomalies.
• MRI is used to diagnose inflammatory and
infectiouc spinal disorders and in cases in
which CNS or neck malignancy is suspected.