Torticollis in Children
Summary
Torticollis ("Twisted Neck") describes an abnormal neck posture where the head tilts towards the affected side and the chin rotates to the opposite side. The most common cause in infancy is Congenital Muscular Torticollis (CMT), caused by fibrosis/shortening of the Sternocleidomastoid (SCM) muscle. However, in older children, new-onset (acquired) torticollis is a suspicious sign that requires exclusion of serious pathology, including Posterior Fossa Tumours, Cervical Spine Trauma/Subluxation, and Ocular causes. Management depends entirely on the aetiology: physiotherapy for CMT, but urgent imaging/referral for acquired cases with red flags. [1,2]
Key Facts
- The "Cock Robin" Position: Head signals "Yes" (Tilt) and "No" (Rotation) simultaneously.
- Example: Right SCM tightness = Right Ear to Shoulder (Tilt Right) + Chin points Left (Rotation Left).
- Congenital Muscular Torticollis: Often associated with a palpable "mass" (fibromatosis colli) in the SCM and developmental dysplasia of the hip (DDH).
- Plagiocephaly: Positional flattening of the skull is a common secondary complication of CMT (baby always lies on one side).
- Grisel's Syndrome: Non-traumatic Atlanto-axial subluxation following an upper respiratory infection or ENT surgery (inflammation causes ligament laxity).
Clinical Pearls
The Eye Exam is Mandatory: A child with a "wry neck" might actually have a IVth Nerve (Trochlear) Palsy. They tilt their head to align the images and avoid diplopia. Always perform a cover test.
Tumour Rule: Acquired torticollis + Morning Vomiting + Ataxia = Posterior Fossa Tumour until proven otherwise.
Sandifer Syndrome: Torticollis caused by severe Gastro-Oesophageal Reflux Disease (GORD). The arching helps relieve discomfort.
Benign Paroxysmal Torticollis of Infancy: Recurrent episodes of head tilt in an infant (migraine variant). Self-limiting.
Congenital Muscular Torticollis (CMT)
- Prevalence: 0.3 - 2% of newborns.
- Ranking: 3rd most common congenital musculoskeletal anomaly (after DDH and Clubfoot).
- Associations: DDH (2-8% risk), Metatarsus Adductus.
Acquired Torticollis
- Common in older children.
- Usually muscular spasm or viral myositis ("stiff neck").
1. Congenital Muscular Torticollis
- Mechanism: Ischaemia/Trauma to SCM muscle during intrauterine positioning or difficult delivery (breech/forceps).
- Pathology: Fibrosis replaces muscle fibers -> Shortening -> Contracture.
- Mass: A "sternomastoid tumour" (fibrotic olive) may be palpable at 2-3 weeks, resolving by 4-6 months.
2. Atlanto-Axial Rotary Subluxation (AARS)
- C1 (Atlas) rotates on C2 (Axis) and gets stuck ("Locked Facet").
- Can be traumatic or inflammatory (Grisel's).
3. Klippel-Feil Syndrome
- Congenital fusion of cervical vertebrae. Short neck, low timeline.
History
Features
Inspection
- Observe posture.
- Look for facial asymmetry (eye smaller on affected side).
- Look for plagiocephaly.
Palpation
- SCM: Palpate the entire muscle belly.
- CMT: Tight band or "olive" mass.
- Trauma: Tenderness.
- Spine: Spinous process tenderness (Trauma/Osteomyelitis).
Movement
- Passive ROM:
- Try to gently rotate chin to the affected side (restricted in CMT).
- Try to tilt ear to opposite shoulder (restricted in CMT).
Systems
- Eyes: Extra-ocular movements.
- Hips: Barlow/Ortolani (Check for DDH).
- Neuro: Cerebellar signs, Long tract signs.
Imaging in Infants (CMT)
- Ultrasound Neck: Confirm SCM mass vs Lymph node.
- Ultrasound Hips: Screen for DDH (if CMT present).
Imaging in Acquired / Red Flags
- Cervical Spine X-Ray: AP, Lateral, Open Mouth Peg. (Rule out bony fracture/fusion).
- CT Neck (3D Recon): Gold standard for Atlanto-Axial Rotary Subluxation.
- MRI Brain/Spine: If neurological signs or persistent pain.
Management Algorithm
CHILD WITH TORTICOLLIS
↓
ONSET & AGE GROUP?
┌─────────┴─────────┐
INFANT (less than 6m) CHILD (>6m)
(Likely CMT) (Likely Acquired)
↓ ↓
Check Hips RED FLAGS?
Physio + (Neuro/Trauma)
Positioning ↓ ↓
↓ YES NO
Resolved? ↓ ↓
NO YES MRI/CT Analgesia
↓ Refer Soft Collar
Surgery? Review 1 wk
1. Management of Congenital Muscular Torticollis (CMT)
- Physiotherapy (First Line):
- Stretching: Gentle passive stretching by parents (Chin to shoulder, Ear to opposite shoulder) at every nappy change.
- Positioning: "Tummy time". Place toys/crib stimulation on the side that encourages rotation away from the restriction.
- Efficacy: >90% resolve if started less than 1 year.
- Surgery (Second Line):
- Indications: Failed physio after 12 months, facial asymmetry developing, limitation >15 degrees.
- Procedure: SCM release (Tenotomy) - unipolar or bipolar. Followed by bracing.
2. Management of Acquired Torticollis
- Muscular/Viral: NSAIDs, Heat, Soft collar for comfort (briefly). Spontaneous resolution common.
- Grisel's Syndrome: Antibiotics, Bed rest, Halter traction may be needed.
- AARS: Traction, Bracing (Halo vest rarely).
- Ocular: Surgery to correct squint.
3. Plagiocephaly Management
- Repositioning: Keep off the flat spot.
- Helmet Therapy: Controversial. Used for severe cases (expensive, mixed evidence).
- Facial Asymmetry: Permanent recession of the jaw/face on affected side (due to muscle tension restriction growth).
- Scoliosis: Compensatory curves.
- Ambylopia: Visual loss if ocular cause missed.
- CMT: Excellent prognosis. Most resolve by age 1.
- Late diagnosis (>1 year): High failure rate of physio, usually needs surgery.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CMT CPG | APTA (Physio) | Screen for hip dysplasia. Start physio early. Use TOT collar if severe. |
| Neck Masses | AAO-HNS | Ultrasound SCM mass to confirm fibromatosis vs malignant mass. |
Landmark Knowledge
1. Cheng et al. (2000)
- Study: Large cohort of CMT.
- Result: Recognized the "SCM Tumor" group, "Muscular" group, and "Postural" group.
- Key Finding: Hip dysplasia present in ~8%. Mandated hip screening.
What is Congenital Torticollis?
It means the neck muscle (SCM) on one side is too tight or short. This pulls the baby's head to one side. It can happen if they were squashed in the womb.
Will it get better?
Yes. With simple stretching exercises, most babies get better completely within months.
The Exercises
- Rotation: Gently turn the baby's chin towards the tight side (stretches the rotation).
- Tilt: Gently tilt the baby's ear towards the opposite shoulder (stretches the length). Do this at every nappy change. It might be uncomfortable for them, but it is not damaging.
What is the lump?
You might feel a small lump in the neck muscle. This is just scar tissue healing. It will disappear on its own.
Primary Sources
- Kaplan SL, et al. Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline from the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther. 2018;30:240-290.
- Herman MJ. Torticollis in infants and children: common and unusual causes. Instr Course Lect. 2006;55:647-653. PMID: 16958498.
- Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006;18:26-29.
Common Exam Questions
- Paediatrics: "Neonate with right torticollis. Next investigation?"
- Answer: Ultrasound Hips (check for DDH).
- ENT: "Child with torticollis follows a throat infection. Diagnosis?"
- Answer: Grisel's Syndrome (Atlanto-axial subluxation).
- Oncology: "Torticollis + morning headache + vomiting. Diagnosis?"
- Answer: Posterior Fossa Tumour. URGENT MRI.
- Anatomy: "Action of Left SCM?"
- Answer: Tilts to Left, Rotates to Right.
Viva Points
- Klippel-Feil Syndrome: Triad of Short neck, Low hairline, Limited ROM. (Fused vertebrae).
- Sternomastoid Tumour: Is it cancer? No. It is fibromatosis colli (benign fibrosis). Don't biopsy it.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.