Torticollis
Torticollis: Excerpt from Professional Guide to Diseases (Eighth Edition)
Torticollis, sometimes called wryneck, is a neck deformity in which the sternocleidomastoid neck muscles are spastic or shortened, causing bending of the head to the affected side and rotation of the chin to the opposite side.
Causes and incidence
Torticollis may be congenital or acquired. The three types of acquired torticollis — acute, spasmodic, and hysterical — have differing causes. The acute form results from muscular damage caused by inflammatory diseases, such as myositis, lymphadenitis, or tuberculosis (TB); from cervical spinal injuries that produce scar tissue contracture; and, less commonly, from tumor or medication. The spasmodic form results from rhythmic muscle spasms caused by an organic central nervous system disorder (probably due to irritation of the nerve root by arthritis or osteomyelitis). Hysterical torticollis is due to a psychogenic inability to control neck muscles.
Acquired torticollis usually develops during the first 10 years of life or between ages 30 and 60. Incidence of congenital (muscular) torticollis is highest in infants after difficult delivery (breech presentation), in firstborn infants, and in girls. Possible causes of congenital torticollis include malposition of the head in utero, prenatal injury, fibroma, interruption of blood supply, or fibrotic rupture of the sternocleidomastoid muscle, with hematoma and scar formation.
Signs and symptoms
The first sign of congenital torticollis is commonly a firm, nontender, palpable enlargement of the sternocleidomastoid muscle that’s visible at birth and for several weeks afterward. It slowly regresses during a period of 6 months, although incomplete regression can cause permanent contracture. If the deformity is severe, the infant’s face and head flatten from sleeping on the affected side; this asymmetry gradually worsens. The infant’s chin turns away from the side of the shortened muscle, and his head tilts to the shortened side. His shoulder may elevate on the affected side, restricting neck movement.
The first sign of acquired torticollis is usually recurring unilateral stiffness of neck muscles followed by a drawing sensation and a momentary twitching or contraction that pulls the head to the affected side. This type of torticollis commonly produces severe neuralgic pain throughout the head and neck. (See Recognizing torticollis.)
Diagnosis
A history of painless neck deformity from birth suggests congenital torticollis; gradual onset of painful neck deformity suggests acquired torticollis. Diagnosis must rule out TB of the cervical spine, pharyngeal or tonsillar inflammations, spinal accessory nerve damage, ruptured transverse ligaments, subdural hematoma, tumors of soft tissue or bone, dislocations and fractures, scoliosis, congenital abnormalities of the cervical spine and base of the skull, rheumatoid arthritis, and osteomyelitis. In acquired torticollis, cervical spine X-rays are negative for bone or joint disease but may reveal an associated disorder (such as TB, scar tissue formation, tumor, deformities, or arthritis). Computed tomography scan or magnetic resonance imaging may help rule out pathogenic causes.
Treatment
Treatment of congenital torticollis aims to stretch the shortened muscle. Nonsurgical treatment includes passive neck stretching and proper positioning during sleep for an infant and active stretching exercises for an older child — for example, touching the ear opposite the affected side to the shoulder and touching the chin to the same shoulder.
Surgical correction involves sectioning the sternocleidomastoid muscle; this should be done during preschool years and only if other therapies fail.
Treatment of acquired torticollis aims to control pain and correct the underlying cause of the disease. In the acute form, application of heat, cervical traction, and gentle massage may help relieve pain; analgesics may also be helpful. Stretching exercises and a neck brace may relieve symptoms of the spasmodic and hysterical forms. Drug treatment includes anticholinergic drugs such as baclofen. Botulinum toxin injections are effective in temporarily relieving torticollis, but injections must be repeated every 3 months.
Special considerations
Patient care for torticollis includes the following:
❑ To aid early diagnosis of congenital torticollis, observe the infant for limited neck movement, and thoroughly assess his degree of discomfort.
❑ Teach the parents of an affected child how to perform stretching exercises with him. Suggest placing toys or mobiles on the side of the crib opposite the affected side of the child’s neck to encourage the child to move his head and stretch his neck.
❑ If surgery is necessary, prepare the patient by shaving the neck to the hairline on the affected side.
After corrective surgery:
❑ Monitor the patient closely for nausea or signs of respiratory complications, especially if he’s in cervical traction. Keep suction equipment available to prevent aspiration.
❑ The patient may be in a cast or in traction day and night or at night only. Monitor the skin around the chin, ears, and back of the head if the patient is in cervical traction. Monitor for problems related to clenching of teeth. If the patient is in a cast, give meticulous cast care, including the monitoring of circulation, sensation, and color around the cast. Protect the cast around the patient’s chin and mouth with waterproof material. Check for skin irritation, pressure areas, or softening of cast pad.
❑ Provide emotional support for the patient and his family to relieve their anxiety due to fear, pain, limitations from the brace or traction, and an altered body image.
❑ Begin stretching exercises as soon as the patient can tolerate them.
❑ Before discharge, explain to the patient or his parents the importance of continuing daily heat applications, massages, and stretching exercises, as prescribed, and of keeping the cast clean and dry. Emphasize that physical therapy is essential for a successful rehabilitation after the cast is removed.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
More About Torticollis
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- Torticollis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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