TORTICOLLIS

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Torticollis, also known as wryneck, is a condition that causes the head to tilt or twist to one side. It can affect both babies and adults, though the causes and treatments differ slightly. Here’s a breakdown of what you need to know:

What is torticis?

The word “torticollis” comes from Latin, with “tortus” meaning twisted and “collum” meaning neck. The main symptom is a tilted head, often accompanied by difficulty turning the head in both directions.

Types of Torticollis

Newborn Nods: Congenital Torticollis

The most common type of torticollis is congenital, meaning it’s present at birth. This often happens because of positioning in the womb or the use of forceps or a vacuum during delivery. These factors can tighten the sternocleidomastoid (SCM) muscle on one side of the baby’s neck, causing the head to tilt.

Acquired Torticollis: More Than Just Newborns

While less frequent, torticollis can also develop later in infancy or childhood (acquired torticollis). This could be due to infections, injuries, or even muscle imbalances. Adults can also experience torticollis, sometimes as a side effect of medication or due to injuries.

Causes

In infants:

1. In Utero Positioning: Sometimes, infants experience torticollis due to cramped conditions in the womb or an abnormal positioning, like being breech, which applies pressure on one side of the head, leading to tightening of the SCM.
2. Delivery Assistance: The use of forceps or vacuum devices during delivery may also exert pressure on the baby’s SCM, contributing to torticollis.
3. Other Factors: Congenital torticollis can also be caused by abnormalities in SCM development, Klippel-Feil syndrome (a rare birth defect), hematoma (blood buildup in neck muscles), or fibrosis (muscle tissue thickening).
4. Acquired Torticollis Causes: This type may result from throat swelling due to infections or injuries, vision problems, GERD (stomach acid irritation in the esophagus), medication reactions, scar tissue, neck arthritis, Sandifer syndrome (acid reflux-induced muscle spasms), or Grisel’s syndrome (rare after certain surgeries).
5. Unknown Causes: Sometimes, torticollis occurs without identifiable reasons, termed idiopathic torticollis.

In Adults:

1. Cervical Dystonia: Also known as spasmodic torticollis, this form typically affects adults, leading to neck muscle spasms.
2. Triggers: Cervical dystonia may arise from head or neck injuries, adverse reactions to medications for mental health conditions, or genetic mutations inherited.

Torticollis, whether in infants or adults, can have diverse origins, ranging from developmental factors to injuries and medical conditions. Understanding these causes aids in appropriate diagnosis and treatment strategies.

Symptoms

Torticollis manifests with various symptoms, differing between infants and adults.

In infants:

1. Head Tilting: The infant’s head tilts to one side, with the chin pointed towards the opposite shoulder, typically affecting the right side in about 75% of cases.
2. Limited Head Movement: Difficulty turning the head side to side or up and down easily.
3. Palpable Lump: A soft lump may be felt in the baby’s neck muscle, usually resolving within 6 months.
4. Preference in Vision: The baby may prefer looking over one shoulder, avoiding turning the head fully to follow objects or people.
5. Breastfeeding Difficulties: Trouble breastfeeding on one side or showing a preference for feeding on one side only.
6. Struggle in Movement: Effortful attempts to turn towards stimuli, accompanied by visible discomfort.
7. Flat Head: Possibility of developing a flat head on one or both sides due to prolonged positioning, known as positional plagiocephaly.
8. Uneven Shoulders: One shoulder may appear higher than the other.
9. Muscle Tightness: Presence of muscle tightness or stiffness in the neck area.
10. Swollen Neck Muscles: Observable swelling in the neck muscles.
11. Facial Asymmetry: Uneven facial features, such as one eye appearing lower than the other.

Symptoms of Acquired Torticollis in Infants:

1. Severe Pain or Headaches: Exhibiting signs of severe neck pain or headaches.
2. Head and Chin Tilting: Head tilts to one side while the chin tilts to the other.
3. Muscle Tightness: Tight, stiff, or swollen neck muscles.
4. Limited Movement: Restricted movement in the head and neck area.
5. Uneven Shoulders: Presence of uneven shoulder levels.
6. Head Tremors: Shaking or trembling movements of the head.

in Adults:

1. Muscle spasms or tremors: muscles twitching, jerking, or shaking involuntarily.
2. Tense Neck Muscles: feeling of stiffness or tension in the neck muscles.
3. Pain and Burning: Experience of pain or burning sensations in the shoulders, neck, or back.
4. Headaches: the occurrence of headaches, often associated with neck discomfort.
5. Head Movement Abnormalities: Tilting, bending, or turning the head in unusual directions or patterns.

Diagnosis

If you suspect your baby has torticollis, it’s crucial to schedule an examination with your doctor promptly.

Diagnosis in infants:

1. Physical Examination: The doctor will assess how far your baby can turn their head and may observe other relevant signs.
2. Imaging Scans: X-rays, CT scans, MRIs, and ultrasounds might be ordered to detect underlying conditions. An electromyogram (EMG) can identify the affected muscles, while blood tests help rule out other linked conditions.
3. Additional Conditions: Approximately 1 in 5 babies with torticollis may have concurrent hip problems. Although most infants with torticollis don’t experience other medical issues, it’s essential to consider potential links to infections, fractures, medication allergies, or genetic syndromes like Down syndrome or Klippel-Feil syndrome.

Diagnosis in Adults:

1. Physical Examination: Doctors will conduct a thorough physical exam, inquire about family medical history, and evaluate symptoms.
2. Tests: Imaging tests such as MRI and EMG are typically unnecessary unless there are suspicions of spinal cord compression or nerve damage.

Importance of Prompt Attention:

It’s vital not to overlook symptoms that may indicate serious conditions. Meningitis, characterized by inflammation of the membranes covering the brain and spinal cord, can resemble torticollis. Seek immediate medical assistance if you experience symptoms such as sudden high fever, chills, stiff neck, severe headache, confusion, trouble concentrating, or a skin rash.

Complications

Acting early to address torticollis in infants is crucial for preventing potential long-term complications. Without proper treatment, the following complications may arise:

1. Limited Head Control: Difficulty in controlling the head’s movement.
2. Reduced Reach and Eye Tracking: Limited reach and diminished ability to track objects with the eyes on the affected side.
3. Developmental Delays: Delays in achieving milestones such as sitting and walking.
4. Feeding Challenges: Difficulties in feeding properly.
5. Balance and Motor Skill Issues: Poor balance, crooked crawling, rolling onto one side only, and delays in motor skill development.
6. Facial Deformities: Possibility of facial deformities due to prolonged muscle imbalance.
7. Flat Head Syndrome: Development of flat spots on the head from lying on one side excessively.
8. Motor Skill Delays: Delays in acquiring motor skills.
9. Hearing and Vision Problems: Potential issues with hearing and vision development.

In adults, torticollis complications may include:

1. Balance Problems: Difficulties in maintaining balance.
2. Altered Gait: Changes in the way one walks.
3. Bone Spurs: Formation of bony lumps on the edge of bones.
4. Underlying Serious Conditions: Torticollis in adults may be indicative of a more severe underlying condition such as injury, tumor, or infection.
5. Disability: In some cases, torticollis can lead to a disability that interferes with everyday life.
6. Emotional Issues: Psychological challenges may arise due to the physical limitations and discomfort associated with torticollis.

Early intervention and appropriate management are crucial for minimizing the risk of these complications and promoting optimal physical and emotional well-being for both infants and adults with torticollis.

Treatment for torticollis

In Infants:

1. Stretching Exercises: Most cases of congenital torticollis can be managed with stretching exercises or changes in positioning that can be done at home. These exercises aim to lengthen the tight muscles and strengthen the opposing muscles.
2. Early Intervention: Starting stretching exercises early can significantly improve outcomes, with most babies showing improvement within six months of starting treatment.
3. Home Care Tips:
   • Utilize feeding positions that encourage turning away from the favored side.
   • Place toys strategically to encourage looking in both directions.
   • Encourage hand and foot play to build up the muscles necessary for crawling.
   • Incorporate plenty of supervised tummy time to strengthen back and neck muscles and prevent flattening of the head.
4. Physical Therapy: Your doctor may recommend seeing a physical therapist for additional guidance and support.
5. Surgery: In rare cases where conservative measures fail, surgery to lengthen the sternocleidomastoid muscle may be considered, usually during preschool years.

In Adults:

1. Treatment Options: Treatment for torticollis in adults varies depending on the underlying cause and may include:
   • Physical therapy with heat therapy, massage, and traction devices.
   • Stretching exercises.
   • Bracing or other supportive devices.
   • Medications like baclofen for muscle spasms or anti-inflammatories for pain relief.
   • Botox injections or trigger point injections for muscle relaxation.
   • Spine surgery for vertebral dislocations causing the condition.
2. Home Remedies:
   • Regularly stretch neck muscles.
   • Use hot and cold therapy for pain relief.
   • Ensure adequate rest.
   • Apply gentle pressure to the opposite side of the face, neck, or chin to alleviate spasms.
   • Practice stress reduction techniques.

Prevention

1. Infants: While torticollis cannot be prevented in infants, early intervention and adherence to treatment plans can help avoid complications.
2. Adults: To reduce the risk of torticollis in adults, it’s essential to avoid neck injuries and strains, maintain good posture, and perform regular stretching exercises.

Torticollis can affect individuals of all ages but can often be managed effectively with at-home therapies and medical interventions. Prompt treatment and communication with healthcare providers are key to successful management. If initial treatments are ineffective, consulting with a doctor for alternative options is recommended.

Sources:

• Mayo Clinic: “Gastrointestinal reflux disease (GERD),” “Meningitis,” “Cervical Dystonia.”
• NIH: “Torticollis.”
• Healthdirect.gov: “Torticollis.”
• Mount Nittany Health: “Torticollis, Congenital, Muscular, When Your Child Has.”
• HealthDirect: “Torticollis.”
• Cleveland Clinic: “Torticollis,” “Sandifer Syndrome,” “Cervical Dystonia.”
• Yale Medicine: “Torticollis.”
• Boston Children’s Hospital: “Conditions and Treatments _Torticollis.”
• American Academy of Orthopaedic Surgeons: “Congenital Muscular Torticollis.”
• KidsHealth.org (The Nemours Foundation): “Infant Torticollis.”
• Pediatric Orthopaedic Society of North America: “Study Guide: Congenital Muscular Torticollis.”
• NIH, U.S. National Library of Medicine: “Klippel-Feil syndrome.”