TORTICOLLIS

 Torticollis, also known as wry neck, is a 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 from the Latin words tortus for

twisted and collum for neck.
 TYPES
 Congenital Muscular Torticollis (CMT)
 The congenital muscular torticollis is the most common torticollis which is present at birth. 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
which 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 typically is tilted in
lateral bending toward the affected muscle and rotated toward the opposite side. In other words, in the
direction towards 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 colour histogram or clinically through evaluating the infant's
passive cervical range of motion.
 Congenital torticollis constitutes the majority of cases seen in 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 at the age of two to four weeks. Gradually it disappears, usually by the age of eight months,
but the muscle is left fibrotic.
 Acquired torticollis
 Noncongenital muscular torticollis may result from 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.
 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 may be unrelated to the sternocleidomastoid muscle, instead 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
Congenital Muscular
To r t i c o l l i s
 Introduction

▪ Congenital Muscular Torticollis (CMT) is a congenital

deformity characterized by unilateral shortening of the
sternocleidomastoid muscle resulting in lateral inclination
of the neck associated with contralateral torsion

▪ The term torticollis is derived from the Latin

words tortus for twisted and collum for neck
▪ It is a relatively common recognized infantile
abnormality and its incidence varies from 0.3% to 2.0%
live births
▪ CMT is recorded as is the third most common
congenital musculoskeletal anomaly after dislocation
of the hip and clubfoot
▪ CMT is often associated with
other congenital deformities
such as(DDH) with a
coexistence rate estimated
as high as 14.9%
▪ Other coincident lesions
less frequently recorded
include tibial torsion,
clubfoot, calcaneovalgus
foot, flexible pes planus,
metatarsus adductus, and
hallux valgus
▪ If torticollis persists, patient
will develop scoliosis and the
facial/head asymmetry
known as plagiocephaly.
Aetiology

▪ Postulated that fetal position abnormalities, intrauterine or

perinatal compartment syndrome and birth trauma ensuing a
difficult delivery embody the main causes
▪ Other possible causes encountered are hereditary and venous or
arterial occlusion which may create fibrous tissue within the
sternocleidomastoid
▪ Other possible causes encountered are hereditary and venous or
arterial occlusion which may create fibrous tissue within the
sternocleidomastoid
 Muscular in more than 80% of the cases. Types of muscular torticollis
          - Fibromatosis colli: torticollis with palpable mass in the SCM;
          - Tightness of the SCM without an apparent mass;
 Postural torticollis with neither mass or tightness[.
 Birth trauma: facet dislocation, tears in the sternocleidomastoid muscle
 Congenital anomalies of the craniovertebral junction: occipitoatlantal
fusion or Klippel-Feil syndrome.
 Sternocleidomastoid tumour
 Ocular abnormalities
 Intrauterine mechanical factors
 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 longitudal axis

 anterocollis : forward flexion of the head and neck

 retrocollis : hyperextension of head and neck backward

 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 symptoms include:
 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

 TYPES
 CMT may be categorised into 3 types:
 Postural CMT: no lack in range of movement (ROM) but infant
displays a postural preference
 Muscular CMT: tightness present in sternocleidomastoid and
passive neck ROM restricted
 Sternocleidomastoid mass CMT: fibrotic thickening of
sternocleidomastoid muscle and passive ROM restrictions 
Diagnosis

▪ Diagnosis is based mainly on past medical history

and clinical examination of the infant
▪ A meticulous prenatal history record is essential
and detects complicated labor and the coexistence
of previous birth trauma such as clavicular
fracture.
▪ The presence of perinatal asphyxia, jaundice
seizures, medication, gastroesophageal reflux
disease (GERD) or Sandifer’s syndrome are
also recorded
▪ Ultrasonographic imaging is a useful diagnostic tool with
important diagnostic and prognostic application.with high
sensitivity and specificity of 95.83% and 83.33%, respectively.
▪ Magnetic resonance imaging (MRI) is a modern radiologic
examination with increasing role in CMT diagnosis that have
been found to be correlated with histopathological findings
[19].
 D i ff e r e n t i a l Diagnosis
 Klippel-feil syndrome, grisel syndrome

 Neurological and psychiatric causes of torticollis

 Unilateral hearing difficulty which results in otogenic torticollis,

 Neoplasms,Tumours

 Infections and systematic diseases such as rheumatoid arthritis

 Occipitoatlantal Fusion: characterized by partial or total

fusion of the atlas to the occipital bone. The altered
mechanics of the cervical spine predisposes the atlantoaxial
joint to degeneration and potential instability, resulting in a
dull, aching pain in the posterior neck with intermittent
stiffness and torticollis.
 Managemen
t
▪
 Non Operative Management

▪ Manual passive stretching of the sternocleidomastoid muscle

before the age of 12 months is the most effective mode of
physical therapy
▪ A Program of gentle stretching exercise should include flexion
extension, lateral bending away from involved side and
rotation toward it
▪ Streching exercise shoud be continued until full neck
rotation achieved
▪ Cervical orthosis may be an adjunct and support for children
whose lateral head tilt dosesn’t resolve with exercise or older
children wiyh no longer tolerate strecthing
▪ Botulinum toxin (Botox) could enhance the effectiveness of
stretching on the side of the contracture and allow strengthening
of overstretched and weakened muscles on the opposite side of
the neck.
▪ This method is safe and effective in children and adolescents with
cerebral palsy especially in ambulatory patients
 Operative Management

▪ Surgical release may be considered in children older than 12-18

months of age with CMT resistant to conservative treatment or
in case of facial asymmetry and plagiocephaly development
▪ Surgical techniques to lengthen tight SCMs include unipolar
release, bipolar release,endoscopic release,and subperiosteal
lengthening.
▪ Surgical lengthening of the contracted SCM is mandatory in only
3% of the cases .
▪ Surgery is highly recommended when a restriction of movement
up to thirty degrees is present, as well in cases complicated with
deformities of facial bones
▪ A potential complication of the surgical approach is an injury of the
accessory nerve . The rate of relapse is up to 1.2%.
▪ The optimal time for surgical intervention is referred between 1
and 4 years although favourable results have been also described
for patients 10 years or older at the time of surgery .
▪ Surgical techniques to lengthen tight SCMs include unipolar
release, bipolar release, endoscopic release,and subperiosteal
lengthening.
▪ For aged more than 6 years old, recommend bipolar release .
TECHNIQUE
 Pre Operative P lanning

 Cervical spine should be reviewed– bony anomalies or cervical

scoliosis
 In fixed deformities, positioning of the head can be difficult for
anestesiologist. Flexible fiberoptic intubation shoud be considered
 The ear taped anteriorly and hair around the mastoid process is
shaved
 Positioning

▪ Supine postion , General anestesia

▪ Sanbag placed to elevate the shoulder on the affected side
▪ Draping should permit correction to be evaluated by bending the
neckthe neck is bent toward the unaffected side and the head
rotated to affected side - the SCM muscle kept under tension
and the origin and insertion can be clearly identified
 Incission and d i s s e c t i on

▪ For release the distal pole SCM,

Tranverse incision 3-4long incision 1 cm
superior the clavicle and the two head
the SCM Muscle
▪ The subcutaneus tissue and platysma
muscle are divided inthe lline incission and
the tendon sheats of clavicular and sternal
head exposed
▪ For proximal pole exposure , 2-3 cm
horizontal incisision is made just distal
the tip of mastoid process
▪ The dissection is carried deeper until the
periosteum of mastoid process exposed.
Inserton of muscle exposed
 Distal Unipolar
Release
▪ Release the sternal , some times clavicular head the SCM Muscle

▪ A Transverse Incission placed pararelly zand 1 cm proximal to the clavicle

between calvicular and strenal head of the SCM

▪ An Incission that overlies ove rthe clavicle –hipertrofic sccar,A higher –

jeopardize jugular vein

▪ Two head OF SCM Identified. Surrounding fascia is cleared and strenal head
or
both head is undermined with curved clamp

▪ The Muscle are elevated with the help of clamp and divide with
cautery. Altenatively sternal head can be lengthened by Z Plasty

▪ About 5 -10 mm muscle tendon excised to prevent contracture and

fibrous
formation.

▪ Check bending neck kontralateral and rotating lareal side while palpating
area with finger tip to identified remaining tight
 B i p o l a r Release

▪ Bipolar relaese include the relaese of

the mastoid isertion of SCM Muscle
along with the distal released
▪ The procedure start with a distal
incision
▪ The insertion of the muscle is
identified anteriorly and posterorly
▪ Dissection starts subperiosteally from
mastoid processus to avoid facial nerve
anteriorly and the anterior branch of
the great auricular nerveinferiorly
▪ Release the clavicular head with
lengtheneing of the sternal head by z
plasty may approprate in older children
ti provide simetrical aapearence post
operative
 Post operative Care

▪ Immobilization the head and neck a slightly over

corrected postion with thermoplastic custom
made brace or pinless for 3 weeks
▪ The Brace is removed 3 weeks and passive
stretching is recommeded as well as active
strengthening exercise
▪ Exercised continued for 3-6 weeks
 Out come
▪ Early conservative mangement succesful in over 90 % children
with
CMT who are younger than 1 year
▪ In resistenat cases –still controversy
▪ Cheng et al –excellent result operatedon at age 6 monts to 2 years
with nipolar release
▪ Canale et al better with bipolar release, although the difference
not significan
▪ Wirth et al reported satisfactory result in 48 of 55 patient with
bipolar relaese with low reccurance
 Complication

▪ Wound Breakdown
▪ Hematoma
▪ Residual lateral band
▪ Neurovascular
damage
▪ Hypertohic Scar
Thank You