- Pediatric torticollis is characterized by lateral inclination of the head to the shoulder with neck twisting and facial deviation. - The most common type is congenital muscular torticollis (CMT), caused by unilateral sternocleidomastoid muscle shortening in infants. - CMT is treated initially with gentle stretching exercises but may require surgery if symptoms persist past 12-18 months to lengthen the tight muscle and prevent facial/head asymmetry. Post-operative immobilization and stretching exercises are used.

1. Pediatric Torticollis
Mohamed iliyas Bin Sultan Abdul Kader

2. Outline
• Introduction
• Types
• Approach to Torticollis
• Most common cause (presentation)
• Management (conservative vs operative)

3. Introduction
Torticollis - word derived from latin1
tortus - twisted
collum - neck
It is characterised by lateral inclination of the head to the
shoulder with torsion of the neck and deviation of the face2.
It is also known as wryneck
1. Lee J II , Lim SY , Song HS , Park MC(2010) : Complete tight fibrous band release and resection in congenital muscular
torticollis. J Plast Reconstr Aesthet Surg 63:947-95
2. Hulbert KF(1965) Torticollis: Postgrad Med J 41:699

4. Types
• Congential
Congenital muscular torticollis (most common)
• Acquired
- Trauma (fracture / dislocation)
- Infections
Head and neck ( URTI, Otitis media, mastoiditis, cervical adenitis, retropharyngeal abcess)
Spine ( osteomyelitis, discitis, epidural abscess) Pharyngeal infection with atlantoaxial rotatory
subluxation (Grisel Syndrome)
- Neurogenic
idiopathic spasmodic torticollis
- Ocular dysnfunction
compensation for squint
- Inflammation
Juvenile idipathic arthritis

5. Approach to Peadiatric torticollis
Meticulous history ( prenatal, birth and perinatal)
looking for any asphyxia, complication of labor
Infective: fever, increased drooling, sore throat, dysphagia.
Time course: (Uncomplicated acute torticollis should
resolve within 7 - 10 days without complication.)
Awkward position pre-symptoms, particularly if recent
symptoms.
Neuro: headache, strabismus, diplopia
Trauma

6. Examination
- firm, painless, pseudotumor palpable in few weeks
of life.
(endomysial mass consis for fibrotic tissue with deposition of collagen
and fibroblast around atrophic SCM fibers)3
Assess for midline tenderness, general neck palpation and attempt
active ROM.
Neurologic examination. Eye examination
ENT examination including lymph nodes
3.Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, et al. (2006) Congenital muscular torticollis: evaluation and classification.
Pediatr Neurol 34: 41-44.

7. Investigations
Cervical spine X-ray ( suspcious of fracture/dislocations , if there is spine tenderness,
persistent symptoms)
Ultrasound and CT can be helpful in patients in whom
retropharyngeal inflammation is suspected
CT/MRI: helpful to determine the extent of certain lesions, to
rule out atlantoaxial subluxation if plain films are equivocal,
and to assess patients with neurologic deficits

8. • Congenital Muscular Torticollis
(CMT) is a congenital
deformity characterized by
unilateral shortening of the
sternocleidomastoid muscle
resulting in lateral inclination
of the neck associated with
contralateral torsion.4
Congenital Muscular Torticollis (CMT)
4. Omidi-Kashani F, Hasankhani EG, Sharifi R, Mazlumi M (2008) Is surgery recommended in adults with
neglected congenital muscular torticollis? Aprospective study. BMC Musculoskelet Disord 9: 158

9. • Incidence 0.3% to 2%, and 3rd most common congential
musculoskeletal anomaly after DDH and clubfoot.4,5
• If Torticollis persists, patient will develop scoliosis and the
facial/head asymmetry known as secondary
plagiocephaly.6
5. Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, et al. (2006) Congenital muscular torticollis: evaluation and
classification. Pediatr Neurol 34: 41-44.
6. Hollier L, Kim J, Grayson BH, McCarthy JG (2000) Congenital muscular torticollis and the associated
craniofacial changes. Plast Reconstr Surg 105: 827-835

10. Aetiology
Unknown aetiology, but postulated are fetal position
abnormalities, intrauterine positions and birth trauma
ensuing difficult delivery7
Hereditary and venous or arterial oculsion whcih may create
fibrous tissue within sternoclediomastoid8
7. Davids JR, Wenger DR, Mubarak SJ (1993) Congenital muscular torticollis: sequela of intrauterine or perinatal
compartment syndrome. J Pediatr Orthop13: 141-147.
8.Hollier L, Kim J, Grayson BH, McCarthy JG (2000) Congenital muscular torticollis and the associated craniofacial
changes. Plast Reconstr Surg 105: 827-835.

11. • Manual passive stretching of the sternocleidomastoid
muscle before the age of 12 months is the most
effective mode of physical therapy9
• A Program of gentle stretching exercise should include
flexion extension, lateral bending away from involved side
and rotation toward it
• Cervical orthosis may be an adjunct and support for
children whose lateral head tilt dosesn’t resolve with
exercise or older children wiyh no longer tolerate
strecthing
9. Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, et al. (2010) Congenital muscular torticollis in children: distribution, treatment
duration and out come. Eur J Phys Rehabil Med 46: 153-157.
Non Operative Management

12. Operative Management
Indication:
-children > 12-18 months with resistant to conservative Tx
-in case of facial asymmetry and plagiocephaly
development10
• Surgical techniques to lengthen tight SCMs - unipolar
release, bipolar release,endoscopic release,and
subperiosteal lengthening.
10.Angoules AG, Boutsikari EC, Latanioti EP (2013) Congenital Muscular Torticollis: An Overview. J Gen
Pract 1: 105. doi: 10.4172/2329-9126.1000105

14. • A potential complication of the surgical approach is an
injury of the accessory nerve . The rate of relapse is up to
1.2%.
• The optimal time for surgical intervention is referred
between 1 and 4 years although favourable results have
been also described for patients 10 years or older at the
time of surgery .
• For aged more than 6 years old, recommend bipolar
release .

15. Post operative Care
• Immobilization the head and neck a
slightly over corrected postion with
thermoplastic custom made brace or
pinless for 3 weeks
• The Brace is removed 3 weeks and
passive stretching is recommeded as
well as active strengthening exercise
• Exercised continued for 3-6 weeks

16. Thank You