Torticollis is simply the tilting of the head to one side caused by contraction of the neck muscles and in babies and children, this is usually the sternocleidomastoid muscle, which runs from the base of the skull (mastoid) to the inner front of the collar bone (clavicle) and onto the breast bone (sternum) the muscle turns the head and pulls the side of the neck downwards. Torticollis is a description, not a diagnosis in itself, but is a sign of an underlying cause. Torticollis can be divided into two broad categories: Congenital (born with) and acquired (following injury or infection).
By far the most frequent is Congenital muscular torticollis (CMT) – previously called Sternocleidomastoid tumour – which is a cause of abnormal head posture in infants. It is usually noticed within the first month of life. It is seen as a result of birth trauma, or foetal position within the uterus. CMT causes shortening and scarring due to fibrosis of the sternocleidomastoid muscle which can be felt as a small lump (previously called a tumour - but it is simply, scar tissue) within the muscle. CMT can occur in the absence of a lump felt in the muscle.
There are other rarer conditions that result in congenital torticollis e.g. abnormalities of the spine in the region of the neck (cervical spine), the Arnold-Chiari malformation a malformation of the base of the skull, spina bifida. Additionally, torticollis may be a feature of some rare muscular diseases.
Treatment of Congenital Muscular Torticollis (CMT)
This is best managed by a physio with experience of the condition and positioning the infant so they need to turn their heads to the affected side and stretch the muscles.
Congenital muscular torticollis responds very well to physiotherapy, especially when it’s started early. Sometimes it is associated with plagiocephaly, a common and treatable condition in which there is an asymmetry in the shape of the head and face. This happens because the forces of gravity pull unevenly on a baby’s tilted head, causing a flattened appearance on one side of the skull or face. All of this will improve as the torticollis gets better and rarely needs any additional treatment.
Acquired torticollis has a broad range of causes:
Again the most frequent cause in childhood is following trauma to the neck leading to Muscle spasm ("wry neck").
However, infection in the head and neck areas - such as a simple upper respiratory tract infection (URTI) middle ear infection(otitis media), inflammation of the mastoid bone in the skull (mastoiditis), inflamed lymph nodes in the neck (cervical adenitis), tonsillar infection leading to an abscess (retropharyngeal abscess), dental infection, and bone infection in the spine (osteomyelitis, discitis, epidural abscess) can all cause wry neck or torticollis.
Trauma and ligamentous laxity (e.g. as part of underlying disorders) also may cause similar problems.
When trying to assess the cause of the torticollis the story of how and when the neck problem was seen is important, and the majority are either in babies or young children, which helps rule out many of the rare causes. The doctor or healthcare worker assessing your child will need to examine the entire child, not just the neck. In babies, there is often some head shape changes and even hip problems, all of which are caused by the same factors which caused the torticollis originally.
Further advice and treatment depend on the cause or underlying diagnosis:
For muscle spasm reassurance that it should get better in about 1 week and simple pain relief with Paracetamol or Ibuprofen is all that is needed.
Appropriate antibiotics in the case of infection.
Referral to another specialist if an abscess is suspected.
Refer to orthopaedic doctors if a bony cause is suspected.