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Torticollis
ICD-10 M436
ICD-9 723.5
OMIM [1]
DiseasesDB 31866
MedlinePlus [2]
eMedicine emerg/597 orthoped/452
MeSH {{{MeshNumber}}}


Torticollis, (or Requa neck or wryneck) , is a dystonia and is a condition in which the head is tilted toward one side, and the chin is elevated and turned toward the opposite side.

In children

Torticollis can be congenital or acquired.

Congenital muscular torticollis

The etiology of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to cause damage to the sternocleidomastoid muscle in the neck. [How to reference and link to summary or text] This results in a shortening or excessive contraction of the sternocleidomastoid muscle, often with limited 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.

The reported incidence of congenital torticollis is 0.3-2.0 %.[1] Sometimes a mass (a sternomastiod tumor) in the affected muscle may be noted, this appears at the age of two to four weeks, it disappears gradually, but sometimes the muscle becomes fibrotic. It is likely to disappear within the first five to eight months of life.

The condition is treated initially with physical therapy, with stretching to correct the tightness, strengthening exercises to achieve muscular balance, handling to stimulate symmetry. A TOT Collar is sometimes used. About 5–10% require surgery,[2][3] "surgical release" of the muscle if stretching fails.

Infants with torticollis have a higher risk for plagiocephaly. Altering the head position and using a pillow when supine helps as does giving a lot of tummy time when awake.

Other less common causes such as tumors, infections, ophthalmologic problems and other abnormalities should be ruled out. For example, ocular 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 facial asymmetry can develop. [How to reference and link to summary or text] Head position should corrected before adulthood (to about the age of 18 there can be improvement). Younger children show the best results.

Congenital torticollis develops in the infant but can be diagnosed at older ages, even in adults who were missed as infants/children.

The word torticollis means wry neck: Acquired torticollis is not the same as congenital torticollis. All ages can suffer from acquired torticollis.

A common, but effective, treatment involves a multi-phase process:
1) Low-impact exercise to increase strong form neck stability
2) Physical therapy manipulation of the neck.
3) Extended heat application.
4) Repetitive shiatsu massage.

Acquired torticollis

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.
  • The use of certain drugs, such as antipsychotics, can cause torticollis.[4]
  • There are many other rare causes of torticollis.

Evaluation

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 adults

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.


Treatment

Operant conditioning

EMG feedback

Hypnosis

Drugs

Antiinflammatories

Physicians will normally prescribe an anti-inflammatory,as well as advise the patient to receive physical therapy manipulations of the cervical spine (neck) which has been shown to help aid in recovery and reduce healing 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.

=Muscle relaxants

It is also possible to have a muscle relaxant or antispasmodic drug injected into the body to help speed recovery.

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.

See also

References

  1. 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.
  2. Tang SF, Hsu KH, Wong AM Hsu CC, Chang CH. Logitudinal followup study of ultrasonography in congenital muscular torticollis. Clin Orthop. 2002;403:179-185.
  3. 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.
  4. Dressler D, Benecke R (November 2005). Diagnosis and management of acute movement disorders. J. Neurol. 252 (11): 1299–306.

Further reading

  • Amancio, E. J., Peluso, C. M., Santos, A. C. G., Magalhaes, C. C. P., Pires, M. F. C., Dias, A. P. P., et al. (2002). Ekbom's syndrome and spasmodic torticollis: Case report: Arquivos de Neuro-Psiquiatria Vol 60(1) Mar 2002, 155-158.
  • Anatasopoulos, D., Nasios, G., Psilas, K., Mergner, T., Maurer, C., & Lucking, C. H. (1998). What is straight ahead to a patient with torticollis? : Brain: A Journal of Neurology Vol 121(1) Jan 1998, 91-101.
  • Andersen, N. B. (1983). A home training programme for spasmodic torticollis patients treated with EMG feedback: Scandinavian Journal of Behaviour Therapy Vol 12(1) 1983, 57-60.
  • Ansari, K. A., & Webster, D. D. (1974). Quantitative measurements in spasmodic torticollis: Description of a method and results of measurement: Diseases of the Nervous System Vol 35(1) Jan 1974, 44-47.
  • Avampato, J. A. (1975). Hypnosis: A cure for torticollis: American Journal of Clinical Hypnosis Vol 18(1) Jul 1975, 60-62.
  • Berger, H. J., Van Hoof, J. J., Van Spaendonck, K. P., Horstink, M. W., & et al. (1989). Haloperidol and cognitive shifting: Neuropsychologia Vol 27(5) 1989, 629-639.
  • Bertolotti, G., & Colombo, R. (1992). A computerized acquisition system for a biofeedback laboratory: Experiences in the assessment of primary muscular focal dystonia patients: Rivista di Psichiatria Vol 27(3) May-Jun 1992, 99-103.
  • Biary, N., & Koller, W. (1985). Effect of alcohol on dystonia: Neurology Vol 35(2) Feb 1985, 239-240.
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