Torticollis, also called wryneck or twisted neck is a condition caused by tightening or shortening of neck muscles. Often, children with this condition have poor head control and tilt their head towards one side while the chin is turned to the other side. This is usually observed in the first 6 to 8 weeks of life. In newborns, it occurs as a result of the abnormal positioning of the head of the fetus in womb and some infants may also have hip dysplasia. In older children, it may result from injury to the neck muscles or infections.

Causes
Torticollis may be an inherited defect or an acquired condition. Torticollis may be caused by various reasons.

• Inheritance: Gene mutations may result in different types of birth defects which may cause torticollis in the newborn.
• Acquired causes of torticollis in children are:

Injury to the neck muscles such as minor trauma caused by sleeping in an abnormal position (sleeping on the stomach or with head turned to one side) or dislocation/fracture of the vertebrae in the neck.

Infection in the neck: Infection or inflammation of lymph node may interfere with the movement of neck. Retropharyngeal abscess (deep infection causing abscess in the throat) is common in children of 2-4 years.

Injury or diseases of the nervous system.

• Congenital torticollis present at birth may be caused by abnormal positioning of the growing fetus’s head in the womb which results in injury to the neck muscles.

Signs and Symptoms

Child with torticollis may exhibit various signs and symptoms.

• Painless swelling or mass in the neck (appears in infants during the first month).
• Tilting of the head to one side with the chin pointing the shoulder on the opposite side.
• Limited ability to move the neck or turn the head.
• One side of the face and head looks flattened (plagiocephaly) because child may rest the head always on the same side while sleeping.
• Pain and stiffness in the neck are characteristic symptoms in torticollis caused by injury or infection.

Diagnosis
Your orthopedic physician will diagnose torticollis based on the birth history which reveals the possibility of any birth injury and a careful physical examination. X-rays and ultrasound examination of the neck and hips may be done to rule out other abnormalities and confirm the diagnosis. A thorough neurologic exam helps to assess the cause of the disease.

Treatment
Treatment for torticollis depends on the cause and is generally a conservative approach. Treatment includes physical therapy exercises and medical therapy. In rare cases, if muscle stiffness persists and limits head movement in children even after the age of 1 year, surgery may be considered.

Conservative Treatment

Medical Therapy
The medications prescribed for the treatment of acquired torticollis include analgesics (nonsteroidal anti-inflammatory drugs) and anticholinergic drugs.

Botulinum toxin type A injection may be given to the neck muscles to improve the range of motion. Most of the cases of acquired torticollis are self-limiting and resolve within 2 weeks.

Physical Therapy
Physical therapy consists of a manual stretching exercise which involves turning the head in such a way that the chin touches each shoulder and also the ear touches the shoulder. It is helpful in the treatment of congenital torticollis, before the age of 1 year. Physical therapy exercises aims at stretching the shortened neck muscles. Passive stretching and positioning can be done in infants and small children. These treatments are successful when started within 3 months of birth.

Surgical Correction
Surgery to correct the neck muscle may be recommended if the conservative approach is a failure or inappropriate and in children those develop facial asymmetry.

The surgery is performed in a hospital operating room under general anesthesia. Your surgeon will make 3 – 4 cm long incision on the skin over the affected sternocleidomastoid muscle of the neck. The muscle is dissected free from its attachment to the bone. It is done using diathermy to prevent excess blood loss. The incision is sutured and a surgical dressing is placed.

Surgery may also be performed using minimally invasive technique, endoscopic tenotomy of sternocleidomastoid muscle,

Surgical repair completely resolves the condition and recurrence is rare. Following the surgery follow-up may be recommended until surgeon confirms the complete resolution of the condition where the child will be able to rotate the head and neck in all directions.