Torticollis


Torticollis, also known as wry neck, is an extremely painful, dystonic condition defined by an abnormal, asymmetrical head or neck position, which may be due to a variety of causes. The term torticollis is derived.
The most common case has no obvious cause, and the pain and difficulty in turning the head usually goes away after a few days, even without treatment in adults.

Signs and symptoms

Torticollis is a fixed or dynamic tilt, rotation, with flexion or extension of the head and/or neck.
The type of torticollis can be described depending on the positions of the head and neck.
  • laterocollis: the head is tipped toward the shoulder
  • rotational torticollis: the head rotates along the longitudinal axis towards the shoulder
  • anterocollis: forward flexion of the head and neck and brings the chin towards the chest
  • retrocollis: hyperextension of head and neck backward bringing the back of the head towards the back
A combination of these movements may often be observed. Torticollis can be a disorder in itself as well as a symptom in other conditions.
Other signs and symptoms include:
A multitude of conditions may lead to the development of torticollis including: muscular fibrosis, congenital spine abnormalities, or toxic or traumatic brain injury.
A rough categorization discerns between congenital torticollis and acquired torticollis.
Other categories include:
  • Osseous
  • Traumatic
  • CNS/PNS
  • Ocular
  • Non-muscular soft tissue
  • Spasmodic
  • Drug induced
  • Oral ties

    Congenital muscular torticollis

Congenital muscular torticollis is the most common torticollis that is present at birth. Congenital muscular torticollis is the third most common congenital musculoskeletal deformity in children. The cause of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle in the neck. Other alterations to the muscle tissue arise from repetitive microtrauma within the womb or a sudden change in the calcium concentration in the body that causes a prolonged period of muscle contraction.
Any of these mechanisms can result in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its 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. In other words, the head itself is tilted in the direction of the shortened muscle, with the chin tilted in the opposite direction.
Congenital torticollis is presented at 1–4 weeks of age, and a hard mass usually develops. It is normally diagnosed using ultrasonography and a color histogram or clinically by evaluating the infant's passive cervical range of motion.
Congenital torticollis constitutes the majority of cases seen in paediatric clinical practice. The reported incidence of congenital torticollis is 0.3-2.0%. Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle. Congenital Muscular Torticollis is also defined by a fibrosis contracture of the sternocleidomastoid muscle on one side of the neck. Congenital torticollis may not resolve on its own, and can result in rare complications including plagiocephaly. Secondary complications associated with Congenital Muscular Torticollis include visual dysfunctions, facial asymmetry, delayed development, cervical scoliosis, and vertebral wedge degeneration which will have a serious impact on the child's appearance and even mental health.
Benign paroxysmal torticollis is a rare disorder affecting infants. Recurrent attacks may last up to a week. The condition improves by age 2. The cause is thought to be genetic.

Acquired torticollis

Noncongenital muscular torticollis may result from muscle spasm, trauma, scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic or permanent. The latter type may be due to Pott's Disease.
  • A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common and will pass spontaneously in 1–4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds, or unusual postures are implicated; however, in many cases, no clear cause is found. These episodes are commonly seen by physicians.
Most commonly this self-limiting form relates to an untreated dental occlusal dysfunction, which is brought on by clenching and grinding the teeth during sleep. Once the occlusion is treated it will completely resolve. Treatment is accomplished with an occlusal appliance, and equilibration of the dentition.
  • Tumors of the skull base 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.
  • The use of certain drugs, such as antipsychotics, can cause torticollis.
  • Antiemetics - Neuroleptic Class - Phenothiazines
  • There are many other rare causes of torticollis. A very rare cause of acquired torticollis is fibrodysplasia ossificans progressiva, the hallmark of which is malformed great toes.

    Spasmodic torticollis

Torticollis with recurrent, but transient contraction of the muscles of the neck and especially of the sternocleidomastoid, is called spasmodic torticollis. Synonyms are "intermittent torticollis", "cervical dystonia" or "idiopathic cervical dystonia", depending on cause.

Trochlear torticollis

Torticollis can be caused by damage to the trochlear nerve, which supplies the superior oblique muscle of the eye. The superior oblique muscle is involved in depression, abduction, and intorsion of the eye. When the trochlear nerve is damaged, the eye is extorted because the superior oblique is not functioning. The affected person will have vision problems unless they turn their head away from the side that is affected, causing intorsion of the eye and balancing out the extorsion of the eye. This can be diagnosed by the Bielschowsky test, also called the head-tilt test, where the head is turned to the affected side. A positive test occurs when the affected eye elevates, seeming to float up.

Anatomy

The main job of the sternocleidomastoid muscle is to help move the head and neck by turning the head to one side and bending the neck forward. The sternocleidomastoid muscle gets its blood from different arteries in the neck, which bring oxygen and nutrients to keep the muscle healthy. Torticollis can happen when there are issues with the sternocleidomastoid muscle, like if it's too short, causing the head and neck to be in an odd position. Torticollis can also be caused by problems with bones, muscles, or the spine in the neck, leading to difficulty moving the head and neck normally. Knowing about the sternocleidomastoid muscle and how it works is crucial for doctors to diagnose and treat torticollis correctly, so they can find and fix the problem causing it. Differences in how the sternocleidomastoid muscle is supplied with blood or nerves can affect how torticollis develops or how well treatments work, so it's important for doctors to consider these variations when planning treatment. Having a good understanding of the neck's anatomy helps doctors accurately diagnose torticollis and choose the best treatments to help patients feel better.
The sternocleidomastoid muscle gets signals from nerves in the neck and head to contract and move properly. The underlying anatomical distortion causing torticollis is a shortened sternocleidomastoid muscle. This is the muscle of the neck that originates at the sternum and clavicle and inserts on the mastoid process of the temporal bone on the same side. There are two sternocleidomastoid muscles in the human body and when they both contract, the neck is flexed. The main blood supply for these muscles come from the occipital artery, superior thyroid artery, transverse scapular artery and transverse cervical artery. The main innervation to these muscles is from cranial nerve XI but the second, third and fourth cervical nerves are also involved. Pathologies in these blood and nerve supplies can lead to torticollis.

Diagnosis

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.
Ultrasonography can be used to visualize muscle tissue, with a colour histogram generated to determine cross-sectional area and thickness of the muscle.
Evaluation by an optometrist or an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems.
Differential diagnosis for torticollis includes
Cervical dystonia appearing in adulthood has been believed to be idiopathic in nature, as specific imaging techniques most often find no specific cause.