What is Torticollis?
Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”. It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.
What happens in torticollis?
Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles.
Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.
In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2.
Pathophysiology of torticollis
As shown in Fig 2, Torticollis can be of two types.
“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as,
- Intrauterine (inside uterus) malposition of the baby
- Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth.
- Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.
This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults.
Reasons for Acquired Torticollis
- Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion).
- Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
- Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
- Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
- Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
- Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
- Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.
- Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region.
Signs and Symptoms of Torticollis
- Inability to move the neck with limited range of motion
- Chin tilted to one side
- Head tremor
- Neck muscle spasm and pain
- One shoulder is higher than the other
- Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
- Stiffness of the neck muscles
- Swelling of the neck muscles (possibly present at birth)
- Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.
When to seek medical care?
Congenital torticollis can be easily identified after childbirth and determine the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.
How is torticollis diagnosed?
A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI). However, it’s unlikely that the exact cause of the muscle spasm can be isolated.
In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.
How can torticollis be treated?
Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent.
Other problems with delayed treatment
- Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
- Open mouth posture with the tongue pulled to one side or the other.
- Suck/swallow may be affected leading to feeding issues.
- A permanent trunk and facial asymmetry can occur.
Chances of torticollis relapse
Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.
The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.
General goals for treatment,
- Reducing pain, spasm and muscle strains of the neck.
- Improving mobility and flexibility of the soft tissue structures affected.
- Reducing stiffness in the neck and mobilizing the joints of the neck.
- Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
- Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
- Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.
There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery.