eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Torticollis

Author: Gurdeep S Othee, MD, Staff Physician, Department of Emergency Medicine, Medical College of Georgia
Coauthor(s): Carl R Menckhoff, MD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Medical College of Georgia; Lorenzo L Pacelli, MD, Consulting Surgeon, Division of Orthopedic Surgery, Section of Upper Extremity Surgery, Scripps Clinic
Contributor Information and Disclosures

Updated: Feb 5, 2008

Introduction

Torticollis is a condition that causes the neck to involuntarily twist to one side secondary to contraction of the neck muscles. The ear is tilted toward the contracted muscle and the chin is facing the opposite direction. Torticollis is derived from the Latin, tortus, meaning twisted and collum, meaning neck. It is a symptom of diverse conditions. Some of the more common causes include congenital problems, trauma, and infections.^{1,2,3,4,5,6,7,8}

When conservative treatment measures fail, patients may undergo a sternocleidomastoid release, selective denervation, or dorsal cord stimulation.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Torticollis.

Related eMedicine topic:
Neck Trauma

Problem

Torticollis results in a fixed or dynamic posturing of the head and neck in tilt, rotation, and flexion. Spasms of the sternocleidomastoid, trapezius, and other neck muscles, usually more prominent on one side than the other, cause turning or tipping of the head.^7,8

Frequency

Congenital muscular torticollis occurs in fewer than 0.4% of newborns.² For noncongenital muscular torticollis, the average age of onset is 40 years. Women are affected twice as often as men.⁹

Etiology

Local etiology in adults

• Acute wryneck: This is the most prevalent type of torticollis and develops overnight without provocation. It is self-limited, and symptoms resolve in 1-2 weeks.
• Cervical spine torticollis: This may involve injuries from a fracture, dislocation, subluxation, infection, spondylosis, tumor, scar tissue, or ligamentous laxity in the atlantoaxial region.
• Inflammatory torticollis: Inflammatory processes such as myositis, lymphadenitis, or tuberculosis can cause muscular damage.
• Infectious torticollis: Torticollis may occur from infections of the surrounding soft tissue, such as nasopharyngeal abscess, retropharyngeal abscess, cervical adenitis, tonsillitis, mastoiditis, and sinusitis. Torticollis may also occur from infection following trauma.

Compensatory etiology in adults

• Tilting of the head to suppress an essential head tremor
• Tilting of the head to compensate for double vision secondary to ocular muscle palsy

Central etiology in adults

• Idiopathic spasmodic torticollis occurs more frequently in females, and onset typically occurs in those aged 30-60 years.
• Dystonias such as torsion dystonia, generalized tardive dystonia, Wilson disease, L-dopa therapy, and neuroleptic drug–related dystonia.¹⁰

Pediatric local etiology

• Congenital causes, such as pseudotumor of infancy, hypertrophy or absence of cervical musculature, spina bifida, hemivertebrae, and Arnold-Chiari syndrome
• Otolaryngologic causes, such as vestibular dysfunction, otitis media, cervical adenitis, pharyngitis, retropharyngeal abscess, and mastoiditis
• Esophageal reflux
• Syrinx with spinal cord tumor
• Traumatic causes, such as birth trauma, cervical fracture or dislocation, and clavicular fractures
• Juvenile rheumatoid arthritis

Pediatric compensatory etiology

• Strabismus with fourth cranial nerve paresis
• Congenital nystagmus
• Posterior fossa tumor

Pediatric central etiology

• Dystonias include torsion dystonia, drug-induced dystonia, and cerebral palsy.¹⁰

Pathophysiology

Congenital muscular torticollis is believed to be caused by local trauma to the soft tissues of the neck just before or during delivery.² The most common explanation involves birth trauma with resultant hematoma formation followed by muscular contracture. These children often have undergone breech or difficult forceps delivery. The fibrosis in the muscle may be due to venous occlusion and pressure on the neck in the birth canal because of cervical and skull position. Another hypothesis includes malposition in utero resulting in intrauterine or perinatal compartment syndrome. Up to 20% of children with congenital muscular torticollis have congenital dysplasia of the hip as well.^{11,12,13,14,15}

In noncongenital torticollis, the pathophysiology depends on the underlying cause.

Presentation

The patient's head is rotated and twisted to one direction, and the chin is pointed toward the opposite shoulder. Intermittent painful spasms of the sternocleidomastoid, trapezius, and other neck muscles may occur. The neck movements vary from jerky to smooth. The symptoms are usually worsened by standing, walking, and stressful situations.

In the congenital form, the first sign may be a firm nontender enlargement of the sternocleidomastoid muscle visible at birth. This mass, which is more often localized near the clavicular attachment of the sternocleidomastoid muscle, usually enlarges during 4-6 weeks of life and then gradually decreases in size. By age 4-6 months, the mass is usually absent, and the only clinical finding is the contracture of the sternocleidomastoid muscle and the torticollis posture.

Psychological factors such as depression or anxiety also may play a role. A very careful history should be taken, and thorough physical examination should be performed to try to discover the cause.

Indications

For patients in whom conservative measures have failed, including physical therapy and medications, sternocleidomastoid release, selective denervation, or dorsal cord stimulation may be indicated.

In congenital muscular torticollis, a trial of nonoperative treatment for 12-24 months is allowed before surgical intervention is pursued, because 90% of these patients respond to passive stretching within the first year of life.

Relevant Anatomy

See Intraoperative details.

Contraindications

Surgery is contraindicated in patients in whom underlying reversible causes have not been excluded and in those in whom conservative therapy has not been attempted.

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