Torticollis
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Torticollis, or wry neck, is a condition in which the head is tilted toward one side, and the chin is elevated and turned toward the opposite side.
Torticollis can be congenital or acquired. The etiology of congenital torticollis is unclear, but it is thought that birth trauma causes damage to the sternocleidomastoid muscle in the neck, which heals at a shorter length and causes the characteristic head position. Congenital fourth nerve palsy is a frequent cause of congenital torticollis. Sometimes a mass in the affected muscle may be noted, which is usually a contracted region of muscle and may include fibrosis (scar tissue). Such a mass may enlarge during the first month after birth. But with treatment, it is likely to disappear within the first 5 to 8 months of life.
If the condition is detected early in life (before one year of age) it is treated with physical therapy and stretching to correct the tightness. The use of a TOT Collar can also be very effective. This treatment is usually all that is necessary to fix the problem. Particularly difficult cases may require surgical lengthening of the muscle if stretching fails. Also, if the condition does not respond well to stretching, other causes such as tumors, infections, ophthalmologic problems and other abnormalities should be ruled out with further testing. For example, torticollis due to cranial nerve IV palsy should not be treated with physical therapy. In this situation, the torticollis is a neurologic adaptation designed to maintain binocularity. Treatment should be targeted at the extraocular muscle imbalance. In general, if torticollis is not corrected before one year of age, facial asymmetry can develop and may become impossible to correct.
Acquired torticollis occurs because of another problem and usually presents in previously normal children. Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically. Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases. Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or surgically resected. There are many other rare causes of torticollis.
Evaluation of a child with torticollis begins with history taking to determine circumstances surrounding birth, and any possibility of trauma or associated symptoms. Physical examination reveals decreased rotation and bending to the side opposite from the affected muscle; 75% of congenital cases involve the right side. Evaluation should include a thorough neurologic examination, and the possibility of associated conditions such as developmental dysplasia of the hip and clubfoot should be examined. Radiographs of the cervical spine should be obtained to rule out obvious bony abnormality, and MRI should be considered if there is concern about structural problems or other conditions. Evaluation by an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems (IV cranial nerve palsy, nystagmus-associated "null position," etc.). Most cases in infants respond well to physical therapy. Other causes should be treated as noted above.
Wry Neck can also occur in adults for various reasons, such as an injury to the neck or simply sleeping in an awkward position. One may find that upon awakening it is extremely difficult to lift one's head or is extremely painful to move it. Doctors will normally prescribe an anti-inflammatory, but the pain will subside on its own given time. Once the severity of the pain begins to lessen gentle and increasing movement of the head should begin to restore the full range of motion. It is also possible to have a muscle relaxant injected into the body to help speed recovery.
