Torticollis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Torticollis, also known as wry neck, is a condition in which the head is tilted to one side while the chin is turned towards the opposite shoulder. It can be congenital or acquired and may involve the muscles, nerves, or bones of the neck.

Aetiology

Torticollis can be caused by various factors, which are classified as congenital or acquired:

• Congenital muscular torticollis: The most common form, often resulting from a shortening of the sternocleidomastoid muscle, possibly due to birth trauma or intrauterine positioning.
• Acquired torticollis: Can occur due to various causes, including:
  • Infections such as upper respiratory infections or throat infections leading to reactive muscle spasm.
  • Trauma to the neck or spine, resulting in muscle spasm or vertebral injury.
  • Spasmodic torticollis, a neurological condition characterised by involuntary muscle contractions.
  • Cervical spine abnormalities, such as vertebral subluxation or disc herniation.
  • Ocular torticollis, caused by visual disturbances that lead the head to tilt to correct double vision.
  • Medications, particularly those causing dystonia as a side effect.

Pathophysiology

The pathophysiology of torticollis involves:

• In congenital muscular torticollis, fibrosis and shortening of the sternocleidomastoid muscle, possibly due to birth trauma or intrauterine positioning, cause the characteristic head tilt.
• In acquired torticollis, muscle spasm or structural abnormalities of the cervical spine lead to the abnormal positioning of the head.
• Spasmodic torticollis involves dystonic contractions of the neck muscles, often related to dysfunction in the basal ganglia.

Risk Factors

• Birth trauma or difficult delivery (for congenital muscular torticollis)
• Intrauterine positioning (breech presentation)
• Previous neck injury or trauma
• Neurological disorders, particularly dystonia
• Infections of the upper respiratory tract or throat
• Use of medications known to cause dystonia
• Ocular abnormalities leading to compensatory head positioning

Signs and Symptoms

The signs and symptoms of torticollis include:

• Head tilt towards one side with the chin rotated towards the opposite side
• Limited range of motion in the neck
• Neck pain or discomfort, which may worsen with movement
• Asymmetry in the face or head shape in congenital torticollis due to prolonged abnormal positioning
• Palpable tightness or lump in the sternocleidomastoid muscle in congenital cases
• In cases of spasmodic torticollis, involuntary muscle contractions or twitching in the neck muscles

Investigations

Specific investigations to diagnose torticollis include:

• Clinical examination: Assessment of neck posture, range of motion, and muscle tightness or spasms.
• Ultrasound: May be used in infants with congenital muscular torticollis to assess the sternocleidomastoid muscle.
• Radiography (X-rays): To rule out bony abnormalities of the cervical spine, such as fractures or subluxations.
• MRI or CT scan: In cases of suspected neurological involvement or if structural abnormalities are suspected.
• Blood tests: To rule out infections or inflammatory conditions that may cause secondary torticollis.

Management

Primary Care Management

• Physical therapy: The mainstay of treatment, particularly for congenital muscular torticollis. It includes stretching exercises, positioning techniques, and encouraging normal neck movement.
• Pain management: NSAIDs or other analgesics to manage discomfort associated with muscle spasm.
• Education: Parents of infants with congenital torticollis should be educated on proper positioning during feeding and sleeping to encourage normal neck movement.

Specialist Management

• Referral to a specialist: Indicated for persistent cases, particularly if there is suspicion of underlying neurological or structural abnormalities.
• Botulinum toxin injections: For spasmodic torticollis, botulinum toxin may be injected into the affected muscles to reduce spasm and improve posture.
• Surgical intervention: In severe congenital cases or when conservative management fails, surgery may be required to lengthen the sternocleidomastoid muscle.
• Treatment of underlying conditions: If torticollis is secondary to infections, ocular disorders, or medication side effects, addressing the underlying cause is essential.

References

1. NHS (2024) Torticollis (Wry Neck). Available at: https://www.nhs.uk/conditions/torticollis-wry-neck/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Neck Pain and Torticollis. Available at: https://cks.nice.org.uk/topics/neck-pain-torticollis/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Torticollis: Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h3600 (Accessed: 24 June 2024).
4. American Academy of Neurology (2024) Torticollis. Available at: https://www.aan.com/Guidelines/home/GetGuidelineContent/676 (Accessed: 24 June 2024).

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