What Is Torticollis

We have all experienced that painful muscle spasm in our necks when we sleep in an uncomfortable position the night before. Sometimes, it can be so painful that we cannot turn our necks from side to side, and it is more comfortable when kept in one position, usually to the side. This is called torticollis.

Torticollis is coined from the Greek words “tortum” and “collum”, meaning twisted neck. It is the abnormal positioning of the head and neck in which the head tilts to one side as a result of contractions in the neck muscles.¹ Torticollis is a very common condition. It is estimated that for every 10 people, 9 would experience a form of torticollis in their lifetime.² It occurs twice as frequently in people assigned female at birth than in those assigned male at birth.²

What are the types of torticollis?

Torticollis can be divided into 2 main types based on the age at which the symptoms are noticed. These 2 types are Congenital and Acquired. Congenital torticollis is seen from birth and usually occurs due to problems with muscle development. Acquired torticollis is seen usually after 4–6 months of age into adulthood.³

What are the causes of Torticollis?

To better understand the causes of torticollis, it is helpful to group them into congenital and acquired.

Congenital causes are those related to abnormal muscular or structural development in the intrauterine life of an individual. The muscle most involved in congenital torticollis is the sternocleidomastoid muscle, so much so that congenital torticollis is defined in relation to the sternocleidomastoid muscle. Although there is no proven congenital cause of torticollis, there are suspected causes.

Suspected causes relating to the muscles themselves include abnormal intrauterine position, childbirth injuries and reduced blood supply to the sternocleidomastoid muscle. Abnormal intrauterine position, proposed to be the commonest of the above causes, is said to be associated with reduced space in the womb. Anything which causes reduced intrauterine space is said to be a risk factor for abnormal intrauterine position which may lead to congenital torticollis. Such factors include reduced amniotic fluid (oligohydramnios), first pregnancies and presence of tumours (such as fibroids) in the womb.

Other suspected causes not related to the muscles include vertebral abnormalities, fusion of the first vertebral bone to the occipital bone, Klippel-Feil syndrome and pterygium colli. These causes affect the bones or the skin and could cause congenital torticollis.¹

Acquired causes are causes that develop usually after 4–6 months of age. These causes could be related to the sternocleidomastoid muscle, the skin or bones in the neck, injuries to the muscles in the eyes or tumours in the head or neck.

Injuries to the sternocleidomastoid muscle and sometimes the trapezius muscles have been implicated as causes of acquired torticollis. Injuries to the skin of the neck causing scars such as in burns, can lead to torticollis because the scars form by a shortening of the skin. Conditions affecting the vertebrae including a disc prolapse or an infection in the vertebrae can cause torticollis. Infections of the glands in the neck, abscess formation in the neck, muscle spasms in the neck, irritation of the nerves in the neck or tumours in the base of the head or the neck can lead to torticollis. Sometimes, when there is a disorder in the muscles which create eye movement, the muscles of the head and neck compensate for that disorder leading to spasms in the head and neck muscles which cause torticollis. Strokes are known to cause torticollis and problems with balance have been implicated as well. At other times, there is simply no physical cause at all, and it could be physical or emotional stress or sudden movements that have caused the torticollis.²

What are the characteristics of torticollis?

The characteristic position of the head in torticollis is a head tilt to one side with a concurrent rotation of the chin to the opposite side. There is also stiffness of the neck muscles and pain may or may not be present.

How is Torticollis diagnosed and evaluated?

Diagnosing torticollis doesn’t stop at recognising the signs of torticollis but involves finding out the probable cause of the condition. Your doctor will systematically and thoroughly ask questions, perform examinations, and do investigations to determine the cause of the condition.

Your doctor will probably ask when the symptoms started. This will enable them to differentiate congenital from acquired torticollis. Questions such as presence of a fever or signs of infection, headaches, nausea or visual disturbances, possible injuries to the neck, events around birth, possible structural abnormalities or any family history of genetic disorders, medications and even questions on your emotional state are important to ask as they help to find out what could be causing the torticollis you have.

Examination would include noting your posture, the position of your head in relation to your neck, the range of motion in your neck and whether or not your neck muscles or bones are sore to touch. Other general examinations like your temperature, an ear, nose and throat exam and a neurological exam are also important when evaluating torticollis.

Usually, a thorough history and examination will reveal the cause of this condition but in cases that are still unclear, investigations such as X-rays, CT scans, ultrasound scans, MRIs or blood tests checking for infection markers or genetic abnormalities are vital.^1,2

What is the treatment for torticollis?

The treatment for torticollis, whether congenital or acquired, is largely the same. When properly treated, nearly all children with congenital torticollis improve during their first year. Treatment is grouped into conservative, medical and surgical interventions.^1,2

Conservative management includes the use of physiotherapy and collars, especially in congenital torticollis. Physiotherapy involves stretching and muscle strengthening exercises. The frequency of physiotherapy exercises can range from once to thrice weekly. These exercises can be very effective in the management of torticollis. Sometimes, a collar is used to keep the neck in a neutral position.

Medications are used to reduce the spasm in the muscles which help relieve symptoms seen in torticollis. Other medications used target the anxiety that may occur in this condition. Some of the medications used include benzodiazepines, muscle relaxants and anticholinergics. In some situations, botulinum toxin injections are used.

Some causes of torticollis will not improve with physiotherapy and/or medications. These require surgical procedures to relieve the symptoms. Surgeries can help in lengthening shortened neck muscles or correcting structural abnormalities that create torticollis.

What is the prognosis for Torticollis?

The prognosis for congenital torticollis is very good, as nearly all children with congenital torticollis respond to physiotherapy. Early treatment also improves craniofacial symmetry in children with torticollis. Causes relating to certain infections such as retropharyngeal abscess resolve with treatment of the underlying conditions. In other chronic conditions such as genetic or structural abnormalities, continuous support from a multidisciplinary team of healthcare professionals is necessary.¹

Torticollis can cause isolation and affect an individual’s mental health due to the nature of the condition, so mental health professionals are a vital part of the multidisciplinary team managing a patient with torticollis.¹

Summary

Torticollis is an abnormal position of the head in relation to the neck as a result of contractions in the muscles in the neck. It may be congenital or acquired and it has varied causes. Treatment is generally with the use of physiotherapy, medications and surgical interventions and can be very effective when started early enough.