Torticollis

For the bird, see wryneck.

Torticollis
Classification and external resources
A guinea pig with wry neck
ICD-10	M 43.6
ICD-9	723.5
DiseasesDB	31866
eMedicine	emerg/597 orthoped/452
MeSH	D014103

Torticollis, or wryneck, is a stiff neck associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature (a condition in which the head is tilted to one side). The muscles affected are principally those supplied by the spinal accessory nerve.

1 Classification
2 Diagnosis
3 In animals
4 References
5 External links

Classification

Torticollis can be congenital or may be acquired.

Congenital muscular torticollis

The etiology of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle in the neck. This results in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its range of motion in both rotation and lateral bending. The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side. Noncongenital muscular torticollis can result from scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine).

The reported incidence of congenital torticollis is 0.3-2.0 %.^[1] Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle at the age of two to four weeks. Gradually it disappears, usually by the age of eight months, but the muscle is left fibrotic.

Initially, the condition is treated with physical therapies, such as stretching to release tightness, strengthening exercises to improve muscular balance, and handling to stimulate symmetry. A TOT Collar is sometimes applied. About 5–10% of cases fail to respond to stretching and require surgical release of the muscle. ^[2]^[3]

Infants with torticollis have a higher risk of plagiocephaly. Altering the head position and using a pillow when supine and frequently lying prone when awake help reduce the risk.

Uncommon causes such as tumors, infections, ophthalmologic problems and any other abnormalities should be ruled out before treatment begins Ocular torticollis due to cranial nerve IV palsy, for one, should not be treated with physical therapy. In that case, the torticollis is a neurological adaptation to maintain binocularity. Treatment should instead aim to improve extraocular muscle imbalance.

If torticollis is not corrected, facial asymmetry often develops. ^[4] Head position needs to be corrected before about the age of 18 for there to be improvement. Younger children show the best results.

Congenital torticollis manifests in infancy but may not be diagnosed until childhood or even adulthood.

The word torticollis means wry neck: Acquired torticollis is not the same as congenital torticollis and may develop at any age.

Common treatments might involve a multi-phase process:

Low-impact exercise to increase strong form neck stability
Manipulation of the neck by a chiropractor, physical therapist, or D.O.†
Extended heat application.
Repetitive shiatsu massage.

†An Osteopathic Physician (D.O.) may choose to use Cranial techniques to properly position the occipital condyles - thereby relieving compression of cranial nerve XI in children with Torticollis. This is an example of Osteopathic Manipulative Treatment.

Acquired torticollis

Acquired torticollis occurs because of another problem and usually presents in previously normal children and adults.

A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common ('stiff neck') and will pass spontaneously in 1–4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds or unusual postures are implicated; however in many cases no clear cause is found. These episodes are rarely seen by doctors other than a family physician.
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.
The use of certain drugs, such as antipsychotics, can cause torticollis.^[5]
Antiemetics - Neuroleptic Class - Phenothiazines
There are many other rare causes of torticollis.

Spasmodic torticollis

Main article: spasmodic torticollis

Torticollis with recurrent but transient contraction of the muscles of the neck and esp. of the sternocleidomastoid. "intermittent torticollis . "cervical dystonia"

TREATMENT: Botulinum toxin has been used to inhibit the spastic contractions of the affected muscles.

Diagnosis

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. Some say that congenital cases more often involve the right side, but there is not complete agreement about this in published studies. 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.

In animals

The condition can also occur in animals, usually as a result of an inner ear infection but sometimes as a result of an injury. It is seen largely in domestic rodents and rabbits, but may also appear in dogs and other animals.

References

^ Cheng JCY, Wong MWN, Tang SP, Chen TMK, MPhil, Shum SLF, Wong EMC. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. Bone Joint Surg. 2001;83:679-687.
^ Tang SF, Hsu KH, Wong AM Hsu CC, Chang CH. Longitudinal followup study of ultrasonography in congenital muscular torticollis. Clin Orthop. 2002;403:179-185.
^ Hsu TC, Wang CL, Wong MK, Hsu KH, Tang Ft, Chen Ht. Correlation of clinical and ultrasonographic features in congenital muscular torticollis. Arch Phys Med Rehabil. 1999;80:637-641.
^ Yu C-C, Wong F-W, Lo L-J, et al. Craniofacial deformity in patients with uncorrected congenital muscular torticollis: an assessment from three-dimensional computed tomography imaging. Plast Reconstr Surg. 2004;113:24–33.
^ Dressler D, Benecke R (November 2005). "Diagnosis and management of acute movement disorders". J. Neurol. 252 (11): 1299–306. doi:10.1007/s00415-005-0006-x. ISBN 4150050006. PMID 16208529.