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 bringing the back of the head towards the back
  • Neck pain
  • Occasional formation of a mass
  • Thickened or tight sternocleidomastoid muscle
  • Tenderness on the cervical spine
  • Tremor in head
  • Unequal shoulder heights
  • Decreased neck movement

Causes

A multitude of conditions may lead to the development of torticollis including: muscular fibrosis, congenital spine abnormalities, or toxic or traumatic brain injury.

Other categories include: 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.

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. 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. 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.

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 (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine).

  • A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common ('stiff neck') 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 (posterior fossa tumors) 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 (FOP), 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 (fourth cranial 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. 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.

Ultrasonography can be used to visualize muscle tissue, with a colour histogram generated to determine cross-sectional area and thickness of the muscle.

  • Cranial nerve IV palsy
  • Spasmus nutans
  • Sandifer syndrome
  • Myasthenia gravis
  • Cerebrospinal fluid leak

Cervical dystonia appearing in adulthood has been believed to be idiopathic in nature, as specific imaging techniques most often find no specific cause.

Treatment

Teaching people how to sit and stand properly can help reduce strain on the neck muscles and improve posture. Changing habits like bad posture or repetitive movements can help ease symptoms of torticollis. Injecting a substance like Botox into overactive muscles can weaken them temporarily, allowing for better movement. If other treatments don't work, surgery might be needed to fix the muscles or bones causing torticollis.

Physical therapy

Physical therapy is an option for treating torticollis in a non-invasive and cost-effective manner. Physical therapy is seen as an early conservative intervention to minimize the intensity of the musculoskeletal disorder, leading to short durations of care as well as improved outcomes from treatment. The Physical Therapy Management of Congenital Muscular Torticollis Evidence-Based Clinical Practice Guidelines (CMT CPG) reflects the recommendations and guidelines for physical therapists in diagnosing, treating and educating families of infants with congenital muscular torticollis. Physical therapists that reported using the 2013 CMT CPG in their practices saw patient torticollis resolution in as little as 6-months increase from 42%-61%. As of currently, there is an updated 2024 CMT CMG from the American Physical Therapy Association. In the children above 1 year of age, surgical release of the tight sternocleidomastoid muscle is indicated along with aggressive therapy and appropriate splinting. Occupational therapy rehabilitation in congenital muscular torticollis concentrates on observation, orthosis, gentle stretching, myofascial release techniques, parents' counseling-training, and home exercise program. While outpatient infant physiotherapy is effective, home therapy performed by a parent or guardian is just as effective in reversing the effects of congenital torticollis.

  • Position infant in the crib with affected side by the wall so they must turn to the non-affected side to face out

Physical therapists often encourage parents and caregivers of children with torticollis to modify the environment to improve neck movements and position. Modifications may include:

  • Adding neck supports to the car seat to attain optimal neck alignment
  • Reducing time spent in a single position
  • Using toys to encourage the child to look in the direction of limited neck movement
  • Alternating sides when bottle or breastfeeding

Manual therapy

A meta-analysis shows physical therapists specializing in manual therapy have developed effective interventions for the management of Congenital Muscular Torticollis (CMT), primarily centered around massage and passive stretching techniques. These interventions are tailored to address the specific needs of pediatric patients, with a focus on stretching the sternocleidomastoid muscle. This review did not report any adverse effects of using manipulation techniques. It was shown that using manipulation techniques on their own had little to no statistical differences from a placebo group, immediately. When manipulation techniques were combined with physical therapy, there was a change in symptoms compared to the use of physical therapy alone. When targeting the cervical spine, manipulation techniques were shown to shorten treatment duration in infants with head asymmetries. Microcurrent therapy is completely painless and children can only feel the probe from the machine on their skin.

Surgery

Surgical release involves the two heads of the sternocleidomastoid muscle being dissected free. This surgery can be minimally invasive and done laparoscopically. Usually surgery is performed on those who are over 12 months old. The surgery is for those who do not respond to physical therapy or botulinum toxin injection or have a very fibrotic sternocleidomastoid muscle.

Other treatments

Other treatments include:

  • Encouraging active movements for children 6–8 months of age
  • Ultrasound diathermy

Overview

CMT is a neck problem that babies are born with or develop soon after birth, causing their neck to be stiff and bent in an awkward position. It is possible that torticollis will resolve spontaneously, but chance of relapse is possible.

Head tilt

Causes for a head tilt in domestic animals are either diseases of the central or peripheral vestibular system or relieving posture due to neck pain. Known causes for head tilt in domestic animals include:

  • Encephalitozoon cuniculi infection in rabbits
  • parasitic infestation by the nematode (roundworm) Baylisascaris procyonis in rabbits
  • Inner ear infection
  • Hypothyroidism in dogs
  • Disease of cranial nerve VIII (vestibulocochlear nerve) through trauma, infection, inflammation, or neoplasia
  • Disease of the brain stem caused by stroke, trauma, or neoplasia
  • Damage to the vestibular organ due to toxicity, inflammation or impaired blood supply
  • Geriatric vestibular syndrome in dogs

Notes

References

  • Head Tilt: Causes and Treatment