CHAPTER 38

Sternomastoid Tumour of Infancy and

Congenital Muscular Torticollis
Lukman O. Abdur-Rahman
Brian H. Cameron

Introduction

Sternomastoid tumour (SMT) of infancy is usually associated with congenital muscular torticollis (CMT); these will be discussed together in
this chapter. The term tumour is a misnomer because it is a congenital
fibrotic process; it also is referred to as congenital fibromatosis coli.
The terms torticollis and wryneck actually describe the tilting and
rotation of the head and neck that results from the contracture of the
sternocleidomastoid muscle. The torticollis, when untreated, results in
plagiocephaly, hemifacial hypoplasia, and body distortion. The key to
preventing deformity is early diagnosis and passive stretching exercises
(PSEs) of the affected muscle, with only 5% of cases needing surgical
intervention in a large prospective series.1

to poor neck control in infants before this age (Figure 38.2). Some of
the cases are first noticed by grandmothers while doing the traditional
body massage for the babies.

Physical Examination

A sternomastoid tumour is defined by the presence of a palpable,

hard, spindle-shaped, painless, 13 cm diameter swelling within the
substance of the sternocleidomastoid muscle, usually located in the
lower and middle third of the muscle. The mass may be confused with
a lymph node or neoplasm, which is far less likely at this age.
Children presenting with CMT should have the entire length of the
sternomastoid muscle palpated to determine whether the swelling or area

Demography

The prevalence of SMT and CMT in Africa is unknown.2 At the

University of Ilorin Teaching Hospital in Nigeria over a period of 10
years (19992008), only 15 cases presented at the outpatient clinic
and only one had surgical intervention at 10 months of age because of
severe torticollis. CMT is reported to occur in 0.32% of all births, with
a slight male preponderance. The right side is affected in 60% of the
cases, and 28% are bilateral.3

Aetiology

The sternocleidomastoid muscle is enveloped by the deep cervical

fascia as it attaches to the clavicle, manubrium, and mastoid process.
The aetiology of SMT is unknown, but the current theory is that it
results from abnormal intrauterine positioning, leading to intramuscular
compartment syndrome and ischaemic muscle injury with subsequent
fibrosis and contracture of the sternomastoid muscle.4 Muscle biopsy
shows replacement of muscle bundles with a mass of maturing fibrous
tissueevidence that the pathology may begin prenatally.3
Contracture of the sternomastoid muscle on one side causes the head
and neck to tilt (flex) to the ipsilateral side and the face to turn toward
the contralateral side (Figure 38.1).
If untreated, the sternomastoid tumour naturally resolves completely
in 5070% of the cases by 6 months of age, with muscle shortening
persisting in 57% after 1 year.1,5 Hence, late presentations are usually
accompanied by fibrotic and shortened sternocleidomastoid muscle
from a missed or unrecognised sternomastoid tumour.

Figure 38.1: Sternomastoid tumour on the right side, with the childs head
turned away from the affected side.

Clinical Presentation
History

Infants present with either a lump in the neck, or with a head tilt that
is not correctable by repositioning. SMT is usually absent at birth and
presents between 3 weeks to 3 months of age. There is a high incidence
of breech presentation or assisted delivery. It is important to reassure
the parents that the obstetric difficulty is thought to be the result rather
than cause of the shortened sternomastoid muscle.4
Many parents present their children after 3 months of age in the
African setting because they presume the abnormal position to be due

Figure 38.2: Note the posture of the older baby with left sternomastoid tumour.

Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis 249

of fibrosis is present and in what proportion. More than 50% of children
with CMT will have SMT at the time of presentation.1 The anterior
border of the sternomastoid muscle may reveal a tight band of muscle,
especially in older children. Bilateral sternomastoid tumour with torticollis
creates difficulty in confirming the diagnosis from examination.
Infants with a head tilt will prefer to look away from the affected
muscle. The most important part of the physical exam is to determine the
presence and severity of limitation of passive neck rotation. Gentle neck
rotation with the baby supine and head held over the side of the examining
table should normally allow the chin to reach to or past the shoulder,
90110 degrees from the neutral position (Figures 38.3 and 38.4). With
CMT, there is limited rotation towards the affected side, which can be
graded as mild (>80 degrees), moderate (4580 degrees), or severe (<45
degrees) (Figure 38.5).6
The head should be examined from the back and top of the baby to
document any plagiocephaly, a flattening of the contralateral occiput that
results from persistent lying on one side; this is sometimes accompanied
by contralateral flattening of the forehead (Figure 38.6).
Mild facial asymmetry may be noted, even at an early presentation;
this asymmetry worsens when the torticollis is severe and untreated. The
degree of hemifacial hypoplasia can be determined by the angle between
the plane of the eyes and the plane of the mouth (Figure 38.7).
Older children with long-standing torticollis may have secondary
compensation resulting in musculoskeletal deformities, including elevation
of the ipsilateral shoulder to maintain a horizontal plane of vision, twisting
of the neck and back to maintain a straight line of sight, and wasting
of the neck muscles from disuse atrophy (Figure 38.8).There may be
accompanying muscle spasm with cervical and thoracic scoliosis.
Developmental dysplasia of the hip (DDH) is seen in 58% of
children with CMT, so this should be screened for on the initial physical
examination. Clues on inspection are asymmetric thigh folds and apparent
leg length discrepancy; the Ortolani and Barlow tests for hip stability
should be done. The American Academy of Pediatrics recommends
an ultrasound at 6 weeks of age or radiographs of the hips at 4 months
of age in children at higher risk, which includes girls having breech
presentations.7 No specific mention is made of torticollis as a risk factor,
but DDH may occur in at least 4% of infants with torticollis,5 so it may be
prudent to screen children with hip ultrasound if it is available. Metatarsal
adductus and calcaneovalgus may also be associated with abnormal
intrauterine positioning.

Figure 38.3: Normal rotation of the neck to the left past the shoulder.

Figure 38.4: Limitation of passive neck rotation towards the right (affected) side.

Differential Diagnoses

The clinical features of SMT when associated with CMT are pathognomonic and should not be confused with other lateral neck masses, such as
cystic hygroma, branchial cyst, or hemangioma. Enlarged cervical nodes
are rare in infancy, as are neoplasms.
Congenital torticollis may present without an SMT, but most will still
have some palpable thickening and shortening of the muscle. If there is
a head tilt without any limitation of rotation of the neck, then causes of
postural torticollis should be considered. These would include congenital
hemivertebra, Klippel-Feil syndrome (atlanto-axial fusion), strabismus,
and Sandifer syndrome caused by chronic gastro-oesophageal reflux (see
Table 38.1). Familial and hereditary sternomastoid muscle aplasia have
also been reported.8,9

Figure 38.5: Measurement of passive range of neck motion from the midline.

Investigations

Clinical examination confirms the diagnosis of sternomastoid tumour

and torticollis in most cases, and no investigations are routinely required.
However, imaging studies can occasionally be used to exclude other conditions when the clinical findings are equivocal or atypical.
Plain cervical radiographs are of limited use in nontraumatic infant
torticollis due to their low true-positive yield; more false-positives were
identified in one retrospective review.10 In only 1 of 502 cases was there a
craniocervical anomaly, and the study concluded that physical examination
could safely eliminate the need for routine radiography in infant torticollis.

Figure 38.6: Right occipital flattening (plagiocephaly) with left sternomastoid

shortening.

250 Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis

Ultrasonography has been used to classify, monitor progress, and

predict outcome of congenital muscular torticollis (Table 38.2).11
However, it is not used routinely in most centres, and treatment
decisions should be based on clinical findings. Fine needle aspiration
(FNA) cytology and open muscle biopsy are not necessary and may
be misleading because the histology may look similar to a fibrous
neoplasm. These procedures should be reserved for atypical cases or
when the muscle tumour does not resolve as expected (Figure 38.9).

Management

Figure 38.7: Degree of hemifacial hypoplasia measured by the angle between

the plane of the eyes and mouth (x).

Most cases of SMT and CMT are managed nonoperatively. Babies are
encouraged to actively look towards the affected side. In the University
of Ilorin Teaching Hospital, mothers are encouraged to be turning the
face of the child in the ipsilateral direction while backing their babies
in the traditional way (Figure 38.10). This position also helps in keeping the hip flexed and abducted, preventing or reducing the chance
of a hip dislocation; this could serve as treatment for associated hip
dysplasia. This management replaces the Pavlik harness in the African
setting. For kangaroo bag (frontal child carrier bags) users, this affords
the mother the opportunity to do the massage of the neck and manual
stretching even when in transit.
Minor cases will resolve spontaneously with or without treatment,
but there is evidence that early PSEs are effective in almost all cases
when initiated prior to 3 months of age.5,6,12,13

Passive Stretching Exercises

Figure 38.8: Long-standing right sternomastoid shortening causing facial

asymmetry with secondary neck, shoulder, and back deformities.
Table 38.1: Differential diagnoses of torticollis.
Congenital
1. Sternomastoid tumour
2. Muscular torticollis
3. Congenital vertebral anomalies (cervical hemivertebral)
4. Klippel-Feil syndrome (atlanto-axial fusion)
Trauma
1. Rotary subluxation of atlantoaxial or atlanto-occipital joints (post ear, nose,
throat (ENT) surgery, such as tonsillectomy; retropharygeal abscess drainage)
2. Cervical spine fracture
3. Clavicular fracture
Inflammatory
1. Grisel syndrome
2. Diskitis
3. Vertebral osteomyelitis
4. Juvenile rheumatoid arthritis
5. Cervical disc calcification
6. Retropharyngeal abscess
7. Cervical lymphadenitis
8. Acute lymphoblastic leukaemia
Neurologic
1. Posterior fossa tumour
2. Syringomyelia
3. Arnold-Chiari malformation
4. Paroxysmal torticollis of infancy
5. Cerebral palsy
6. Strabismus
Others
1. Sandifer syndrome in chronic gastro-oesophageal reflux
2. Thymitis
3. Thyroiditis
4. Postural; familial

The PSE technique is as follows:6 With the baby supine and head
suspended over the side of the examining table, one adult holds the
babys shoulders while the other rotates the neck to the same side as the
affected muscle. Gentle but firm pressure and some flexion are applied
at the limit of rotation to maximally stretch the muscle for 1015 seconds (Figure 38.11). This procedure is repeated 10 times, twice daily.
The keys to success are to explain the diagnosis and prognosis to the
parents, demonstrate the PSE, watch them do the PSE in the clinic, and
then follow-up in the clinic at 2 and 6 weeks to ensure progress. Parents
are motivated by telling them that PSE prevents the need for surgery in
most cases. Reassure the parents that babies get used to the exercises
and do not remember the discomfort when they are older. With proper
instruction, PSE will not harm the child. The sternomastoid scar will
occasionally snap, which may lead to some temporary swelling, but
this often results in an improved range of motion.14
The PSE should be consistent and continuous until the muscle
tumour and contracture resolve, generally within 68 months.12 PSE
treatment is successful in more than 90% of cases when commenced
within the first 3 months of life.1,6,13 Emery15 followed 101 children
who started treatment at a mean age of 4 months and found that the
average PSE treatment duration was 4.7 months, with all but one child
achieving a full passive range of motion.
A child older than 68 months of age is less cooperative with the
PSE, and surgery is more likely to be necessary because the contracture
is tighter and more fibrotic.
A physiotherapist can be engaged to do the initial demonstration
and follow-up of progress, especially when mothers are afraid to do
the stretching or there is no response to this treatment as expected.
Physiotherapy would need to be done at least three times a week to
be effective;5 a professional physiotherapist service is an additional
cost that many families would want to avoid and may lead to hospital
default. To prevent this, the confidence of the parents is gained by
providing adequate information and instruction on the pathology and
the treatment options.
A neck brace has been used in older children as an adjunct to PSE
or after surgical treatment.16 If used, the neck brace should be carefully
fitted and not worn at night.
Plagiocephaly can be prevented or treated by positioning the head to
avoid persistent lying on the same side of the occiput. Measures tried

Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis 251

Table 38.2: Ultrasound prediction of outcome of congenital muscular torticollis.
Type I, 15%

Fibrotic mass

Spontaneous resolution

Type II, 77%

Diffuse fibrosis mixing with

normal muscle

Spontaneous resolution

Type III, 5%

Without normal muscle in the

involved muscle

Surgical intervention

Type IV, 3%

Fibrotic cord in the involved

muscle

Surgical intervention (odds

ratio = 31.54, p = .0196)

Source: Adapted from Hsu TC et al. Correlation of clinical and ultrasonographic features of
congenital muscular torticolis. Arch Phys Med Rehabil 1999; 80:637641.

1. late diagnosis, after 12 months of age; and

2. failure after at least 6 months of PSE with a significant head tilt,

persistent deficit of passive neck rotation, and a tight band in the
sternomastoid muscle, often with hemifacial hypoplasia.
There is evidence that surgical release of the sternomastoid
contracture between 12 and 18 months of age maximises spontaneous
correction of plagiocephaly. Surgical correction also results in adequate
mobility and acceptable cosmetics in more than 90% of cases, with
some benefit even in older children.18 Other authors recommend
delaying operative treatment until after 5 years of age, when the patient
can comply with postoperative bracing and physiotherapy.19

Operative ProcedureOpen Technique

1. The patient is placed under general anaesthesia with endotracheal

intubation or the use of a laryngeal mask airway. Anaesthetic
intubation difficulty may arise from abnormal tilt in the trachea, so a
prior cervical x-ray will guide the anaesthetist. Where available, fibreoptic guided endotracheal intubation is the best.
2. The patient is positioned supine with the shoulder raised and neck
rotated to the contralateral side.
Figure 38.9: Residual left sternomastoid swelling in a five-month-old infant at 8
weeks of physiotherapy. The tumour progressively reduced over 4 months.

3. A 34cm transverse skin incision is made 1 cm above the sternal and

clavicular origin of the sternomastoid muscle.
4. The platysma is carefully divided along the line of incision to avoid
injury to the external jugular vein and accessory nerve.
5. The two heads of the sternomastoid muscle are dissected free
from the anterior and posterior layers of the investing fascia and are
subsequently divided using diathermy to prevent bleeding; some
advocate excision of a 1-cm segment of the muscle.18
6. Tight deep cervical fascia should be released, testing lateral and
rotational movement carefully under anaesthetic.
7. In severe cases of contracture, division of the upper end of the
sternomastoid may be necessary.

Figure 38.10: A woman backing an infant with the head turned to the ipsilateral
side of the sternomastoid tumour.

8. The platysma is then sutured with 4-0 interrupted absorbable suture,

and the skin is closed with 5-0 absorbable suture. There is no need for
a drain provided haemostasis is well secured.
Postoperatively, physiotherapy is resumed after wound healing to
maintain a full range of motion; some authors recommend using a neck
brace for several months.18
Alternative surgical approaches that have been described are a
sternomastoid lengthening technique using a Z-plasty,20 and endoscopic
tenotomy of the sternomastoid contracture.21

Postoperative Complications

1. A hematoma usually will resolve, but sometimes requires aspiration

or drainage.
2. Residual contracture from incomplete division of both heads of
sternomastoid or cervical fascia over the posterior triangle of the neck
would need a reoperation.
Figure 38.11: The babys mother does PSE assisted by a friend, while the
surgeon watches.

have included placing toys and desirable objects on the ipsilateral side
of the lesion so that the child turns towards it. The child could also be
put to sleep with the head facing the ipsilateral side. Helmet treatment
has been described in some children with severe plagiocephaly,17 but it
is usually impractical.

Operative Treatment

Surgical treatment is required in only about 5% of patients seen early,

but is necessary in half of those presenting after 6 months of age.6 The
indications for surgery are:

3. Recurrent CMT is rare.

The cosmetic appearance may be disfiguring, especially in the
older child with severe contracture. This is usually due to anomalous
reattachment of the clavicular head of sternomastoid or loss of the
sternomastoid column of the neck.

Prognosis and Outcome

The prognosis for sternomastoid tumour is generally excellent if treated

early. The child is able to achieve full range of head movement, and
the swelling resolves within 6 months. The majority of those who have
surgery also do well.
Follow-up should continue until the sternomastoid muscle resolves
and feels normal, and full neck rotation is achieved. Older children
should be monitored for development of scoliosis.

252 Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis

Sternomastoid tumour

Head tilt
Physical exam:
Is there a limitation of neck rotation
indicating muscular torticollis (CMT)?
Plagiocephaly? Hemifacial hypoplasia?
Check for congenital hip dysplasia.

Tumour without torticollis;

Will usually resolve within 6 months.

If tumour gets
larger, is atypical, or
doesnt resolve by
6 months, consider
further investigations
and biopsy.

Muscular torticollis with tumour or thickening

of sternomastoid muscle: Needs PSE

Age < 12 months:

1. Teach parents passive stretching
exercises.
2. Use traditional backing and ipsilateral
turning of face.
3. Consider physiotherapy referral if
local expertise and cost allow it.

Good response and progress in >90%

of cases.
Follow up until at least 6 months of age
and full range of neck rotation.

Age over 1 year:

Assess degree of limitation of
neck rotation and hemifacial
hypoplasia.

Operative intervention
1. Age > 12months.
2. Failed after 6 months of PSE.
3. Neck rotation <75 degrees.
4. Palpable muscle fibrosis.
5. Progressive facial hemihypoplasia.

Head tilt without muscular torticollis

or tumour:
Look for other causes.

Plain x-ray, CT scan, MRI

Look for other causes.

Refer to
ophthalmologist
neurologist
orthopaedist
neurosurgeon

Consider helmet for persistent severe plagiocephaly

Postoperative physiotherapy and neck brace.

Figure 38.12: Flow chart.

Prevention

There is no primary prevention because the aetiology of sternomastoid

tumour is unknown. Secondary and tertiary prevention strategies will
identify early cases of CMT in children with SMT or breech presentation, initiate early PSE to prevent further deformity, and avoid the need
for surgery. The contracture and torticollis resulting from the sternomastoid tumour should be prevented by early identification, adequate
physiotherapy, and good follow-up.

Ethical Issues

Full involvement and education of the parents in the PSE programme

requires time and compassionate commitment on the part of the
surgeon. Giving information that the mass and head tilt will resolve
spontaneously in many of the children may make mothers default from
regular visits due to the constraint of cost, distance to the hospital,
and long waits in the outpatient clinic. Referral to a costly supervised
stretching programme by the physiotherapist should be avoided if it
will discourage the parents and lead them to default further outpatient
visits. The accessibility and affordability of care make follow-up challenging in the African setting.

Table 38.3: Evidence-based research.

Title

Clinical determinants of the outcome of manual stretching in the

treatment of congenital muscular torticollis in infants. A prospective
study of 821 cases

Authors

Cheng JCY, Wong MWN, Tang SP, Chen TMK, Shum SLF, Wong
EMC

Institution

The Chinese University of Hong Kong and the Prince of Wales

Hospital, Hong Kong, China

Reference

J Bone Joint Surg Am 2001; 83:679687

Problem

The natural history of congenital muscular torticollis and the

outcome of different treatment modalities have been poorly
investigated, and the results of treatment have varied considerably.

Intervention

Standardised program of manual stretching.

Comparison/
control
(quality of
evidence)

The study involved three groups:

1. Palpable sternomastoid tumour group
2. Muscular torticollis group (thickening and tightness of the
sternocleidomastoid muscle)
3. Postural torticollis group (torticollis but no tightness or tumour).
Level 2 evidence.

Outcome/
effect

Controlled manual stretching is safe and effective in the treatment

of congenital muscular torticollis when a patient is seen before
the age of 1 year. The most important factors that predict the
outcome of manual stretching are the clinical group, the initial
deficit in rotation of the neck, and the age of the patient at
presentation.
Surgical treatment is indicated when a patient has undergone at
least 6 months of controlled manual stretching and has residual
head tilt, deficits of passive rotation, lateral bending of the neck
of >15, a tight muscular band or tumour, and a poor outcome
according to a special assessment chart.

Historical
significance/
comments

A sternomastoid tumour was involved in 55% of the patients in

the study.
Eight percent of the sternomastoid tumour group needed surgical
intervention, compared to 3% and 0% in the muscular and
postural torticollis groups, respectively.
The worse the neck rotator deficit, the higher the need for
surgical intervention.

Summary

The flow chart presented in Figure 38.12 summarises the recommendations of this chapter.

Evidence-Based Research

Many prospective studies have been conducted to predict the outcome

of congenital muscular torticollis, but none were randomised. The
study in Table 38.3, however, involves a standardised programme of
manual stretching.

Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis 253

Key Summary Points

1. Sternomastoid tumour is usually associated with congenital
muscular torticollis.
2. All children with sternomastoid tumour should be thoroughly
examined for associated conditions, such as torticollis, facial
and cranial asymmetry, and hip dysplasia.
3. The degree of limitation of rotation of the neck towards the
affected side should be assessed. Congenital muscular
torticollis is a clinical diagnosis that does not require other
investigations.

5. With early diagnosis and treatment, more than 90% of

the cases resolve with an adequately supervised passive
stretching exercise programme.
6. Surgery is indicated in late presentation (>1 year), persistent
limitation of neck rotation with head tilt, and progressive facial
asymmetry.
7. Follow-up should continue until the tumour resolves and neck
rotation normalises.

4. Differentials should be considered and investigated in the

absence of sternomastoid mass or nonresolving torticollis with
nonoperative treatment.

References
1.

2.

3.

4.

Cheng JC, Wong MW, Tang SP, Chen TMK, Shum SLF, Wong
EMC. Clinical determinants of the outcome of manual stretching
in the treatment of congenital muscular torticollis in infants. A
prospective study of 821 cases. J Bone Joint Surg Am 2001;
83:679687.
Nwako FA. Torticollis. In: Nwako FA, ed. A Textbook of Pediatric
Surgery in the Tropics. MacMillan Press Limited, 1980, Pp 277
278.
Beasley S. Torticollis. In: Grosfeld JL, ONeill JA Jr, Fonkalsrud
EW, Coran AG. Pediatric Surgery, 6th ed. Mosby, 2006, Pp
875881.
Davids JR, Wenger DR, Mubarak SJ. Congenital muscular
torticollis: Sequela of intrauterine or perinatal compartment
syndrome. J Pediatr Orthop 1993; 13:141.

5.

Cheng JC, Tang SP, Chen TM, Wong MWN, Wong EMC. The
clinical presentation and outcome of treatment of congenital
muscular torticollis in infantsa study of 1086 cases. J Pediatr
Surg 2000; 35:10911096.

6.

Cameron BH, Langer JC, Cameron GS. Success of nonoperative

treatment for congenital muscular torticollis is dependent on early
therapy. Pediatr Surg Intl 1994; 9:391393.

7.

Goldberg MJ. Early detection of developmental hip dysplasia:

synopsis of the AAP Clinical Practice Guideline. Pediatr Rev 2001;
22:131134.

8.

Adams SB Jr, Flynn JM, Hosalkar HS. Torticollis in an infant

caused by hereditary muscle aplasia. Am J Orthop 2003; 32:
556558.

9.

Hosalkar HS, Gill IS, Guyar P, Shaw BA. Familial torticollis with
polydactyly: manifestation in three generations. Am J Orthop 2001;
30:656658.

10. Snyder EM, Coley BD. Limited value of plain radiographs in infant
torticollis. Pediatr 2006; 118:e1779e1784.

11. Hsu TC, Wang CL, Wang MK, Hsu KH, Tang FT, Chen HT.
Correlation of clinical and ultrasonographic features of congenital
muscular torticollis. Arch Phys Med Rehabil 1999; 80:637641.
12. Celayir AC. Congenital muscular torticollis: early and intensive
treatment is critical. A prospective study. Pediatr Int 2000; 42:504
507.
13. Demirbilek S, Atayurt HF. Congenital muscular torticollis and
strenomastoid tumour. Result of non operative treatment. J Pediatr
Surg 1999; 34:549551.
14. Cheng JC, Chen TM, Tang SP, Shum SL, Wong MW, Metreweli
C. Snapping during manual stretching in congenital muscular
torticollis. Clin Orthop 2001; 384:237.
15. Emery C. The determinants of treatment duration for congenital
muscular torticollis. Phys Ther 1994; 74(10):921929.
16. Symmetric Designs: The TOT Collar for Torticollis Treatment.
Available at: www.symmetric-designs.com/tot-collar-.html
(accessed 30 July 2009).
17. Losee JE, Mason AC, Dudas J, Hua LB, Mooney MP.
Nonsynostotic occipital plagiocephaly: factors impacting onset,
treatment, and outcomes. Plast Reconstr Surg 2007; 119(6):1866
1873.
18. ChengJC, Tang SP: Outcome of surgical treatment of congenital
muscular torticollis. Clin Orthop 1999; 362:190.
19. Azizkhan RG, DeColl JM. Head and neck lesions. In: Ziegler
MM, Azizkhan RG, Weber TR, eds. Operative Pediatric Surgery.
McGraw-Hill Professional, 2003, Pp 221240.
20. Shim JS, Jang HP. Operative treatment of congenital torticollis. J
Bone Joint Surg Br 2008; 90(7):934939.
21. Sasaki S, Yamamoto Y, Sugihara T, Kawashima K, Nohira K.
Endoscopic tenotomy of the sternocleidomastoid muscle: new
method for surgical correction of muscular torticollis. Plast
Reconstr Surg 2000; 105:17641767.