eMedicine Specialties > Pediatrics: Surgery > General Surgery

Torticollis

Author: Amulya K Saxena, MD, Attending Pediatric Surgeon, Department of Pediatric Surgery, Medical University of Graz, Austria
Contributor Information and Disclosures

Updated: Feb 15, 2008

Introduction

History of the Procedure

The earliest description of torticollis dates back to writings from the ancient Greek civilization. According to Plutarch, Alexander the Great may have had torticollis.

Problem

Torticollis is a result of unilateral tightness and shortening of one sternocleidomastoid muscle. A visible or sometimes palpable swelling, often referred to as a sternomastoid tumor, appears in a part of the muscle in infants aged 2-3 weeks. It often persists until they are aged 1 year. It is rarely bilateral and may be seen in older children in whom the mass was not previously identified.

Frequency

Torticollis occurs in 0.4% of all births.

Etiology

The etiology is incompletely understood, although several theories have been postulated.1,2 Reports on the familial transmission of congenital muscular torticollis have been few. An idiopathic intrauterine embryopathy or the intrauterine development of sternocleidomastoid compartment syndrome may be responsible for the sternomastoid fibrosis.

Pathophysiology

An end-arterial branch of the superior thyroid artery supplies the middle part of the sternocleidomastoid muscle. Obliteration of this end artery may be responsible for the development of muscle fibrosis. As an alternative, primary trauma that temporarily and acutely obstructs the veins may lead to intravascular clotting in the obstructed venous tree. In infants, this clotting is evidenced by the development of a sternocleidomastoid mass, which eventually disappears and is replaced by fibrous tissue.

Presentation

The mass is generally 1-3 cm in diameter. It is a painless swelling in the substance of the sternocleidomastoid muscle and develops in neonates aged 2-3 weeks. In infants, the tumor is hard, and the patient's head is tilted and flexed to the side of the fibrosis. However, in older children, the tumor is less discrete than it is in younger children, and the sternocleidomastoid muscle appears thickened and foreshortened along its entire length. This thickening restricts rotation and lateral flexion of the neck.

Older children compensate for the head tilt by elevating their shoulder to maintain a horizontal plane of vision. The head tilting is further compensated by twisting the neck and back, if required, to maintain a straight line of sight. These compensatory mechanisms do not occur in infants, who do not need to maintain a horizontal plane of vision until they stand up. Also, in older patients, muscular spasms play a role or accompany torticollis.

Indications

Management for torticollis is primarily nonoperative, generally consisting of parental physiotherapy.

Rare indications for surgical management include persistent sternocleidomastoid contracture limiting head movement, persistent sternocleidomastoid contracture accompanied by progressive facial hemihypoplasia, and torticollis in children older than 12 months.

Contraindications

Surgical management of congenital muscular torticollis is generally avoided until the child is aged at least 1 year,3 until conservative methods (eg, physiotherapy) are unsuccessful, and until other differential diagnoses are excluded.

More on Torticollis

Overview: Torticollis
Workup: Torticollis
Treatment: Torticollis
Follow-up: Torticollis
Multimedia: Torticollis
References
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References

  1. Bredenkamp JK, Hoover LA, Berke GS, Shaw A. Congenital muscular torticollis. A spectrum of disease. Arch Otolaryngol Head Neck Surg. Feb 1990;116(2):212-6. [Medline].

  2. Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop. Mar-Apr 1993;13(2):141-7. [Medline].

  3. Morrison DL, MacEwen GD. Congenital muscular torticollis: observations regarding clinical findings, associated conditions, and results of treatment. J Pediatr Orthop. 1982;2(5):500-5. [Medline].

  4. Chen MM, Chang HC, Hsieh CF, et al. Predictive model for congenital muscular torticollis: analysis of 1021 infants with sonography. Arch Phys Med Rehabil. Nov 2005;86(11):2199-203. [Medline].

  5. Dudkiewicz I, Ganel A, Blankstein A. Congenital muscular torticollis in infants: ultrasound-assisted diagnosis and evaluation. J Pediatr Orthop. Nov-Dec 2005;25(6):812-4. [Medline].

  6. Celayir AC. Congenital muscular torticollis: early and intensive treatment is critical. A prospective study. Pediatr Int. Oct 2000;42(5):504-7. [Medline].

  7. Collins A, Jankovic J. Botulinum toxin injection for congenital muscular torticollis presenting in children and adults. Neurology. Sep 26 2006;67(6):1083-5. [Medline].

  8. Chate RA. Facial scoliosis from sternocleidomastoid torticollis: long-term postoperative evaluation. Br J Oral Maxillofac Surg. Oct 2005;43(5):428-34. [Medline].

  9. Cheng JC, Tang SP, Chen TM, Wong MW, Wong EM. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases. J Pediatr Surg. Jul 2000;35(7):1091-6. [Medline].

  10. Cheng JC, Wong MW, Tang SP, et al. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. May 2001;83-A(5):679-87. [Medline].

  11. de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg. May 2005;16(3):411-8. [Medline].

  12. Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. Feb 2006;18(1):26-9. [Medline].

  13. Hummel P, Fortado D. Impacting infant head shapes. Adv Neonatal Care. Dec 2005;5(6):329-40. [Medline].

  14. Mikov A. Torticollis in an infant. Am Fam Physician. Oct 15 2007;76(8):1197-8. [Medline].

  15. Munchau A, Bronstein AM. Role of the vestibular system in the pathophysiology of spasmodic torticollis. J Neurol Neurosurg Psychiatry. Sep 2001;71(3):285-8. [Medline].

  16. Munchau A, Corna S, Gresty MA, et al. Abnormal interaction between vestibular and voluntary head control in patients with spasmodic torticollis. Brain. Jan 2001;124(Pt 1):47-59. [Medline].

  17. Opherk C, Gruber C, Steude U, et al. Successful bilateral pallidal stimulation for Meige syndrome and spasmodic torticollis. Neurology. Feb 28 2006;66(4):E14. [Medline].

  18. Parikh SN, Crawford AH, Choudhury S. Magnetic resonance imaging in the evaluation of infantile torticollis. Orthopedics. May 2004;27(5):509-15. [Medline].

  19. Sasaki S, Yamamoto Y, Sugihara T, Kawashima K, Nohira K. Endoscopic tenotomy of the sternocleidomastoid muscle: new method for surgical correction of muscular torticollis. Plast Reconstr Surg. Apr 2000;105(5):1764-7. [Medline].

  20. Shim JS, Noh KC, Park SJ. Treatment of congenital muscular torticollis in patients older than 8 years. J Pediatr Orthop. Nov-Dec 2004;24(6):683-8. [Medline].

  21. Sonmez K, Turkyilmaz Z, Demirogullari B, et al. Congenital muscular torticollis in children. ORL J Otorhinolaryngol Relat Spec. 2005;67(6):344-7. [Medline].

  22. Tatli B, Aydinli N, Caliskan M, et al. Congenital muscular torticollis: evaluation and classification. Pediatr Neurol. Jan 2006;34(1):41-4. [Medline].

  23. van Vlimmeren LA, Helders PJ, van Adrichem LN, Engelbert RH. Torticollis and plagiocephaly in infancy: therapeutic strategies. Pediatr Rehabil. Jan-Mar 2006;9(1):40-6. [Medline].

  24. Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases. Laryngoscope. Apr 2001;111(4 Pt 1):688-95. [Medline].

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Further Reading

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Keywords

torticollis, congenital wryneck, unilateral sternocleidomastoid muscle tightness, sternomastoid tumor, congenital muscular torticollis, sternomastoid fibrosis, progressive facial hemihypoplasia, hematomas, plagiocephaly, facial hypoplasia

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Contributor Information and Disclosures

Author

Amulya K Saxena, MD, Attending Pediatric Surgeon, Department of Pediatric Surgery, Medical University of Graz, Austria
Amulya K Saxena, MD is a member of the following medical societies: European Pediatric Surgeons Association, German Society of Pediatric Surgery, German Society of Surgery, and International Pediatric Endosurgery Group
Disclosure: Nothing to disclose.

Medical Editor

Diana Farmer, MD, Associate Professor, Departments of Clinical Surgery, Pediatrics, Obstetrics, Gynecology and Reproductive Services, Division of Pediatric Surgery and the Fetal Treatment Center, University of California at San Francisco
Diana Farmer, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, and American Pediatric Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Nicholas A Shorter, MD, Professor of Clinical Surgery and Clinical Pediatrics, State University of New York-Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York-Downstate Medical Center
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

 
 
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