This article is in continuation with our previous article on torticollis
Diagnosis
Recognition of congenital muscular torticollis is not usually difficult because of the characteristic cordlike contracture of the sternocleidomastoid muscle. The early fusiform tumor may escape notice. Postural torticollis should be distinguished from congenital muscular torticollis.
The postural deformation is caused by intrauterine malposture, and the deformity is less severe. Although the sternocleidomastoid muscle is shortened, there is no true fibrotic replacement of the muscle. Often there are other findings associated with intrauterine malposture such as pelvic obliquity with abduction-adduction contracture of the hips, or postural metatarsus varus or valgus.
Postural torticollis responds quickly to passive manipulative stretching. I
Torticollis may be caused by contracture muscles other than the sternocleidomastoid, such as the scalenus anterior and the omohyoid.
When surgical release corrected torticollis, the larynx returned to midline position and the asymmetrical face returned to normal. Every patient should have radiograms of the cervical spine made to exclude congenital anomalies of the vertebrae, such as hemivertebrae, unilateral atlanto-occipital fusion, and the Klippel-Feil syndrome.
Differential Diagnosis of Congenital Muscular Torticollis
Congenital Anomalies
- Postural torticollis
- Hemivertebra, cervical-superior dorsal spine
- Unilateral atlanto-occipital fusion
- Klippel-Feil syndrome
- Unilateral congenital absence ofsternocleidomastoid muscle
- Pterygium colli
Trauma-particularly C1, C2
- Rotatory subluxation
- Fracture
Inflammatory conditions unilateral
- Cervical lymphadenitis
- Spontaneous hyperemic subluxation of the atlas
- Rheumatoid arthritis
Neurologic Disorders
- Visual disturbances
- Syringomyelia
- Cervical spinal cord tumor
- Brain tumor, posterior fossa
Treatment
Treatment should be begun as soon as the diagnosis is made. Manipulations consisting of passive stretching of the contracted sternocleidomastoid muscle should be performed by the parents after adequate instruction.
First the head is bent laterally so that the ear on the side opposite the shortened muscle approaches the shoulder, then the head is rotated so that the chin approaches the shoulder of the affected side.
During these manipulations, in order to obtain maximum stretching of the sternocleidomastoid muscle, the neck should be in comfortable hyperextended position and counter traction should be applied by holding the ipsilateral shoulder and chest.
An additional method of stretching the sternocleidomastoid muscle is to make use of gravity by placing the infant supine on the mother’s lap with the head hanging into hyperextension. One hand stabilizes the shoulders and chest, and the other hand tilts the head laterally away from the contracted muscle so that the contralateral ear touches the opposite shoulder. The chin is then rotated toward the contracted muscle.
It is important to hold the muscle stretched to the count of 10. The exercises should be performed 15 to 20 times in each direction, 4 to 6 times a day. In addition, the crib should be turned so that the infant’s unaffected side is against the wall and he will rotate his head to look toward the involved side when his attention is attracted, actively stretching the muscle when reaching and grasping for toys.
Prone posture during sleep should be avoided, as it will aggravate the facial deformities and the contracture.
Ordinarily, if the stretching exercises are begun at a very early age and performed faithfully and correctly every day, the contracture of the sternocleidomastoid muscle will corrected and surgery will not be necessary.
Surgery is indicated when the torticollis does not respond to conservative measures up to one year of age,
or
in cases in which the condition is neglected until the child is a year old or when the parents have not complied in performing an effective exercise regimen.
It is unlikely that the fibrous cord that replaces the sternocleidomastoid muscle can be stretched by manipulation after the age of one year. This is especially true is restriction of rotation of the neck is greater than 30 degrees and there is an established facial asymmetry.
Satisfactory results are usually obtained by division or partial excision of the muscle, provided the head is kept in the corrected position for a sufficient length of time after the operation, and active and passive exercises are carried out to prevent any recurrence of the deformity.
The muscle may be divided at either end or at both ends.
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