Congenital Muscular Torticollis

Discussion

• results from fibrosis of sternal head;
• can result from unilateral shortening of sternocleidomastoid, commonly associated with fibrosis of the muscle;
  • may also involve the platysma and scalene muscles;
  • birth trauma, occlussion of venous flow, or hematoma results in fibrosis of muscle & palpable mass noted w/in first 4 wks of life;
• nontender enlargement may be palpated in body of sternocleidomastoid
• mass usually resolves within the first year of life (90% resolve);
• management should include passive neck stretching;

associated disorders

• bony anomalies of the C-spine, esp involving C1 & C2;
• congenital atlanto-occipital abnormalities;
• congenital webs of skin along the side of the neck, pteygium colli;
• DDH: (20%);
• metatarsus adductus:
• plagiocephaly:
  • w/ persistent contracture of sternocleidomastoid, deformities of face and skull result and are apparent w/ in first year of life;
  • flattening of face is noted on side of contracted sternocleidomastoid and is probably caused by child's sleeping position;
• reference:
  • The coexistence of torticollis and congential dysplasia of the hip.

diff dx in infants »

grisel's syndrome »

• atlantoaxial rotary subluxation in association w/ pharyngeal infection, occurs predominantly in children;
• it results in severe torticollis, resistant to manual therapy;
• > 5 mm of anterior displacement of arch of C-1 (Fielding type III) indicates disruption of both facet capsules as well as transverse ligament;
• reduction w/ skeletal traction, followed by atlantoaxial fusion, is recommended;

rigid torticollis

• see: diff dx
• may also present as rigid deformity, & sternocleidomastoid is not contracted or in spasm;
  • torticollis most often follows an injury to the C1-C2 articulation;
  • frx of the odontoid in young child may not be apparent on initial x-rays;

Non Operative Treatment

• 90% will respond to passive stretching within the first year of life;
• in first yr of life, rx consists of stretching sternocleidomastoid muscle by trying to rotate the head to opposite position;
• stretching exercises should include not only lateral rotation, but also side bending to the opposite shoulder;
• in the study by Cheng JCY, et al (2001), the authors evaluated the outcomes of 821 consecutive patients with congenital muscular torticollis who were first seen when they were less than one year old, were treated with a standardized program of manual stretching, and were followed for a mean of 4.5 years;
  • patients were classified into one of three clinical groups:
    • palpable sternomastoid tumor (452 (55%) had a sternomastoid tumor);
    • muscular torticollis (thickening and tightness of the sternocleidomastoid muscle) (276 (34%));
    • postural torticollis (torticollis but no tightness or tumor) (93 (11%));
  • duration of treatment was significantly associated with the clinical group (p < 0.0001), a passive rotation deficit of the neck (p < 0.0001), involvement of the right side (p < 0.0001), difficulties with the birth (p < 0.009), and age at presentation (p < 0.0001);
  • surgical treatment was required by 8% (thirty-four) of the 452 patients in the sternomastoid tumor group compared with 3% (eight) of the 276 patients in the muscular torticollis group and 0% (none)of the 93 patients in the postural torticollis group;
  • surgical treatment is indicated when a patient has undergone at least six months of controlled manual stretching and has residual head tilt, deficits of passive rotation and lateral bending of the neck of >15°, a tight muscular band or tumor, and a poor outcome according to our special assessment chart;
• ref: Clinical Determinants of Outcome of Manual Stretching in Treatment of Congenital Muscular Torticollis in Infants. A Prospective Study of 821 Cases

Operative Treatment

• indications for surgery:
  • failure of non operative treatment after 12 to 24 months of age, surgical intervention is needed to prevent further facial deformity;
• involves resection of portion of distal sternocleidomastoid muscle from its sternal and clavicular attachments through transverse incision in the normal skin fold of the neck;
• skin incisions immediately adjacent to clavicle may result in unsightly hypertrophic scars.
  • transverse skin incisions in skin folds 1.5 cm proximal to clavicle result in imperceptible scars;
• uncommonly, distal resection is insufficient and proximal release of sternocleidomastoid is needed

• Torticollis in children caused by congenital anomalies of the atlas
• Dynamic computerized tomography of the occiput-atlas-axis complex in trauma patients with odontoid lateral mass asymmetry.
• Biterminal tenotomy for the treatment of congenital muscular torticollis. Long-term results.
• Benign paroxysmal torticollis of infancy.
• Muscular torticollis. A modified surgical approach.
• Congenital muscular torticollis. A long-term follow-up.
• Torticollis.
• Change of Craniofacial Deformity After Sternocleidomastoid Muscle Release in Pediatric Patients with Congenital Muscular Torticollis