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  2. 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. 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. 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. 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. 6. Causes of Torticollis
  7. 7. 1. Congenital muscular torticollis 2. Acquired torticollis
  8. 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. 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. 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. 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. 12. 2- Acquired torticollis
  13. 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. 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. 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. 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. 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. 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. 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. 20. Infectious Causes of Torticollis: Mastoiditis/Bezold’s Abscess
  21. 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. 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. 23. Other causes • The use of certain drugs, such as antipsychotics , Antiemetics , Neuroleptic Class and Phenothiazines , can cause torticollis.
  24. 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. 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. 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. 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.