Pediatric Torticollis Surgery Treatment & Management

  • Author: Amulya K Saxena, MD, PhD; Chief Editor: Marleta Reynolds, MD   more...
 
Updated: Mar 11, 2010
 

Medical Therapy

Medical management of torticollis involves conservative treatment.[12] Sternocleidomastoid fibrosis spontaneously resolves in the vast majority of infants. A large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before age one year.[13, 14] Physiotherapy may be recommended; however, little evidence shows that this alters the course of the condition if the patient is older than one year.

Botulinum toxin type A has been injected into the sternocleidomastoid muscle for the treatment of congenital muscular torticollis in pediatric and adult patients.[15] However, modest benefits with improved range of motion has been observed in very few patients.

Only about 4-5% of patients are surgically treated, generally after the age of 1 year.

Successful bilateral pallidal stimulation has been reported in a patient with Meige syndrome and spasmodic torticollis.[16]

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Surgical Therapy

Patients whose pathology does not resolve after 12 months of physical therapy or who develop facial asymmetry or plagiocephaly during the follow-up period should undergo surgery to achieve the best cosmetic result.[17, 18] In delayed cases, additional surgery may be needed for the best cosmetic and functional result.

Surgery is performed with the patient under general anesthesia. A 3- to 4-cm transverse skin incision is made about 1 cm over the sternal and clavicular origins of the affected muscle. The platysma is carefully divided along the line of incision to avoid injury to the external jugular vein. The 2 heads of the sternocleidomastoid muscle are dissected free. The muscle is divided using diathermy to prevent bleeding. The platysma is then sutured with absorbable 4-0 skin suture, and the skin is closed with continuous 4-0 nonabsorbable skin suture.

An endoscopic or minimal access approach is being offered for the surgical treatment of torticollis. In this approach, muscular torticollis is surgically corrected via endoscopic tenotomy of the sternocleidomastoid muscle.[19]

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Complications

Hematomas may develop because of inadequate hemostasis during surgery. Incomplete division may cause the condition to persist.

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Outcome and Prognosis

Recurrent torticollis after surgery is rare, with a rate of approximately 5%.[20] Even in patients older than school age and those who have finished growth, sufficient unipolar or bipolar release of the sternocleidomastoid muscle and intensive postoperative care are expected to yield satisfactory treatment results.[21]

Secondary effects of untreated torticollis include plagiocephaly, facial hypoplasia, and musculoskeletal effects.

  • Plagiocephaly is an asymmetric skull deformity in infants that is caused by the flattening of one occiput that leads to the secondary flattening of the contralateral forehead. After the torticollis resolves, the plagiocephaly resolves; however, several years may pass before it disappears.[22] Although torticollis can predispose to plagiocephaly without synostosis (PWS), torticollis appears to result from plagiocephaly in a large proportion of cases of plagiocephaly with scoliosis.[23]
  • Facial hypoplasia is inhibition in the growth of the mandible and maxilla due to muscle inactivity. Clinically significant facial hemihypoplasia develops over 8 months; however, it is obvious in patients at the age of 2-3 years. Facial hypoplasia improves as the child grows, after the torticollis resolves.[24]
  • Musculoskeletal effects include the compensatory ipsilateral elevation of the shoulder, as well as cervical and thoracic scoliosis. Wasting of additional muscles in the neck may be present due to sternocleidomastoid inactivity.
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Future and Controversies

Follow-up should be continued until the torticollis resolves completely, until head and neck movement normalize, and until cervical and thoracic scoliosis is resolved in older children.

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Contributor Information and Disclosures
Author

Amulya K Saxena, MD, PhD  Associate Professor, Department of Pediatric and Adolescent Surgery, Medical University of Graz, Austria

Amulya K Saxena, MD, PhD is a member of the following medical societies: Austrian Society for Pediatric and Adolescent Surgery, European Pediatric Surgeons Association, German Society of Pediatric Surgery, German Society of Surgery, International Pediatric Endosurgery Group, and Tissue Engineering and Regenerative Medicine International Society (TERMIS)

Disclosure: Nothing to disclose.

Specialty Editor Board

Diana Farmer, MD  Professor and Chief of Pediatric Surgery, Vice Chair, Department of Surgery, University of California, San Francisco, School of Medicine; Surgeon-in-Chief, UCSF Children's Hospital

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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

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.

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, 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; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric 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.

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. 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].

  4. 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].

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

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

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

  8. 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].

  9. 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].

  10. 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].

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

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

  13. 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].

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

  15. 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].

  16. 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].

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

  18. 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].

  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. 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].

  21. 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].

  22. 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].

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

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

 
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Appearance of torticollis as a result of sternomastoid fibrosis in a young child.
Surgical view of sternomastoid fibrosis shows the thyroid gland (1), the inferior thyroid artery (2), fibrosis of the sternal part of the sternocleidomastoid muscle (3), the brachiocephalic trunk (4), and the normal clavicular part of the sternocleidomastoid muscle (5).
 
 
 
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