Congenital Muscular Torticollis
Torticollis is derived from the Latin, which means twisted neck.
Congenital muscular torticollis or wry neck is the most common form of congenital painless torticollis.
The cause of congenital muscular torticollis remains unknown.
The proposed theories are local compartment syndrome or ischemia involving the neck and producing the fibrotic sternocleidomastoid muscle.
It is hypothesized that the head becomes twisted and rotated in utero, and because of intrauterine crowding and maintaining the same position results in ischemia, edema and eventual fibrosis in the muscle.
Congenital muscular torticollis is associated with developmental dysplasia of hip and foot deformities like metatarsal adductus.
The deformity of the neck is usually obvious at birth or shortly afterward.
The child’s head is tilted towards the involved fibrotic sternocleidomastoid muscle and the chin is rotated towards the opposite shoulder producing the cock robin appearance.
Other feature includes severe plagiocephaly, flattening of the face on the side of sternocleidomastoid lesion and bat ear.
Diagnosis is made by detecting a mass or knot on the involved side of the neck in the body of the sternocleidomastoid muscle in the first 3 months of life.
The mass may regress after early infancy and will be replaced by a readily palpable fibrous contracted band.
Congenital muscular torticollis is a clinical diagnosis.
Investigations are done to rule out other causes of torticollis like vertebral anomalies, failure of segmentation, congenital hemiatlas.
Radiographs of the cervical spine are done to rule out bony abnormalities.
Ophthalmology examination is needed to rule out ocular causes of torticollis.
Non-surgical options are the treatment of choice in the infancy. It provides excellent results in 90% of the cases.
The non-surgical option consists of massage, stretching program, and positioning exercises.
The technique of stretching is taught to parents. It includes stretching of the contracted sternocleidomastoid muscle by rotating the infant’s chin to ipsilateral shoulder and simultaneously tilting the head towards the contralateral shoulder. Stretching should be done gently and achieve a full passive range of motion as quickly as possible.
The positioning of toys and other maneuvers should solicit active rotation towards the involved side.
Surgical treatment is deferred in infants and toddlers, as it results in complications such as scar formation, recurrent contracture with severe fibrosis.
The preferred time for surgical intervention is around 6 years of age.
Operative procedures include unipolar release and bipolar release.
The long term consequences are a craniofacial asymmetry, intermittent head tilt, and mild scoliosis.