| disease | Torticollis |
Torticollis can be divided into congenital muscular torticollis and congenital osseous torticollis. The former is a congenital neck deformity caused by the contracture of the sternocleidomastoid muscle on one side, leading to head and neck tilting, and is relatively common. The latter results from developmental abnormalities of the cervical vertebrae and is less common. This article primarily discusses congenital muscular torticollis.
bubble_chart Etiology
The disease cause of congenital muscular torticollis remains unclear.
However, most scholars believe that abnormal intrauterine pressure or malposition of the fetus is the main cause of congenital muscular torticollis. Improper fetal positioning in the uterus or abnormal pressure from the uterine wall can compress one side of the neck, leading to local circulatory disturbances in the sternocleidomastoid muscle, resulting in ischemic fibrosis and causing torticollis. Some scholars also suggest that embolism of the nutrient vessels of the sternocleidomastoid muscle leads to muscle fiber degeneration, thereby forming torticollis.
Difficult delivery and the use of forceps are considered one of the causes of muscular torticollis. This condition often occurs in breech deliveries, but examination of localized masses in the sternocleidomastoid muscle has not revealed signs of old hemorrhage, so this viewpoint has not been conclusively confirmed.
About one-fifth of affected children have a clear family history, suggesting that the occurrence is related to genetics. Such children often also have other congenital malformations, such as developmental dysplasia of the hip.
bubble_chart Pathological Changes
The mass within the sternocleidomastoid muscle primarily consists of cord-like fibrotic muscle tissue. Gross specimens appear similar to soft fibrous scars, with a white cut surface. Microscopic examination reveals dense fibrous tissue, reduced muscle tissue, and diminished striations. In severe cases, muscle tissue disappears, replaced by abundant scar tissue, but no hemorrhage is observed within the muscle.Based on the proportion of muscle and fibrous tissue, it can be classified into three pathological types:
1. Muscular type: Predominantly composed of muscle tissue, with only small amounts of fibrotic muscle tissue or fibrous tissue.
2. Mixed type: Contains both muscle tissue and fibrous tissue.
3. Fibrous type: Mainly composed of fibrous tissue, with small amounts of muscle or degenerated muscle tissue.
This classification has certain guiding significance for evaluating clinical treatment efficacy. Generally, the muscular type responds better to treatment, while the fibrous type shows poorer outcomes.
bubble_chart Clinical Manifestations
Torticollis Deformity
After birth, the mother may notice that the infant's head tilts toward the affected side, the face rotates toward the unaffected side, and the chin points toward the unaffected shoulder. The torticollis deformity becomes more pronounced after 2–3 weeks. Turning the head toward the unaffected side is significantly restricted, and in milder cases, careful observation is required to detect the condition. This symptom worsens progressively as the child grows.
Neck Mass
A neck mass can usually be palpated at birth or within 2 weeks after birth, located in the middle to lower segment of the sternocleidomastoid muscle, with a higher incidence on the right side. This mass is spindle-shaped, non-tender, and typically reaches its maximum size within 1–2 months before gradually shrinking and disappearing completely. In some cases, the mass may persist, leading to muscle fibrosis and contracture, resulting in torticollis deformity.
If congenital muscular torticollis is not effectively treated in the early stages, facial deformity will develop after the age of 2. The main manifestations include facial asymmetry, with unequal distances from the outer canthus to the mouth corner on both sides—shorter on the affected side and longer on the unaffected side. The plane of the affected eye is lower, and because the eyes are not on the same horizontal line, visual fatigue and reduced vision may occur. The unaffected side of the face appears round and full, while the affected side is narrow and flat. Compensatory scoliosis of the cervical spine may also develop. Additionally, the entire face, including the nose and ears, may exhibit asymmetric changes.
In addition to the above main manifestations, this condition may also be associated with congenital hip dislocation and other cervical spine deformities.
This condition can be easily diagnosed based on typical clinical manifestations and physical examination findings.
bubble_chart Treatment Measures
Non-surgical treatment
For infants under six months of age, non-surgical treatment can achieve satisfactory results. Therefore, once diagnosed, treatment should be initiated as early as possible. Non-surgical methods include local heat application, tuina, bed rest with immobilization, and manual traction. The specific method for manual traction is as follows: the mother places the infant supine on her lap, extends the infant’s neck backward, gently presses the infant’s chest with her left hand, and holds the head and neck with her right hand, rotating the infant’s face as much as possible toward the affected side and the occiput toward the healthy shoulder. The procedure should be performed gently to achieve significant stretching of the contracted sternocleidomastoid muscle. When the infant is in bed, they should lie supine with a small sandbag used to fix the head in a position where the face is turned toward the affected side and the occiput toward the healthy side.
Indications and contraindications for surgery: (1) Suitable for those over six months of age who have not responded to conservative treatment; (2) Those under 12 years of age with obvious torticollis deformity; (3) Those over 12 years of age may also be considered for surgery if facial deformity is not severe; (4) For adults, due to the long-standing deformity, surgery is generally not recommended, as postoperative facial deformity may become more pronounced, and vision may also be affected due to difficulty adapting to the new posture.
The main surgical methods include the following:
Sternocleidomastoid muscle tenotomy: One of the more commonly used surgical methods. A transverse incision is made above the clavicle to expose the sternal and clavicular heads of the sternocleidomastoid muscle, which are severed above their attachment points, and the surrounding fascial tissues are released. Care must be taken during the procedure to avoid injury to the carotid artery, jugular vein, and nerves.
Partial resection of the sternocleidomastoid muscle: For cases with obvious neck masses, the mass segment of the sternocleidomastoid muscle may be excised.
Total resection of the sternocleidomastoid muscle: For adolescent patients, if the entire sternocleidomastoid muscle is scarred, the entire segment may be removed.
Sternocleidomastoid muscle lengthening: The clavicular head of the sternocleidomastoid muscle is severed, and the sternal head is lengthened in a "Z" shape. Advantages of this procedure: (1) Corrects head and neck tilt and restores normal neck movement; (2) Preserves the normal surface contour of the neck triangle, avoiding the凹陷 deformity or abnormal flatness left by other surgical methods, ensuring a symmetrical and aesthetically pleasing neck.
Combined release and plasty of the upper and lower ends of the sternocleidomastoid muscle
Ferkel et al. suggest that this procedure may be used for older children or cases where other surgeries have failed. The method involves complete severing of the mastoid and clavicular heads of the sternocleidomastoid muscle, with the sternal head lengthened in a "Z" shape.
Postoperative management: For severe torticollis deformities or uncooperative children, a head-neck-chest gypsum cast may be required postoperatively to maintain the correct posture.
Attention should be paid to differentiating it from torticollis caused by the following reasons.
Congenital osseous torticollis This condition is mostly caused by congenital occipitocervical deformities, including short neck deformity, basilar invagination, hemivertebra deformity, atlantooccipital fusion, and odontoid process dysplasia. The above diseases can cause torticollis and facial asymmetry, but generally do not produce the typical cord-like contracture band and mass of the sternocleidomastoid muscle. X-ray examination can confirm the above diagnoses.
Pediatric cervical lymphadenitis Infants with cervical lymphadenitis can rapidly develop torticollis and may present with neck masses, but these masses are often significantly tender and not located within the sternocleidomastoid muscle.
Spontaneous atlantoaxial rotatory subluxation Atlantoaxial rotatory subluxation can also cause torticollis, but this condition often has a history of minor trauma or upper respiratory infection, mainly manifesting as limited neck rotation and significant neck pain symptoms, without the tense cord-like band of the sternocleidomastoid muscle. X-ray examination can differentiate it.
Cervical subcutaneous node Cervical subcutaneous node can cause spasm of the sternocleidomastoid muscle and lead to torticollis, but such patients have obvious neck pain, significantly restricted neck movement, and the chin deviates to the affected side. X-ray examination can confirm the diagnosis.
In addition, it is also necessary to differentiate from hysterical torticollis, habitual torticollis, traumatic torticollis, and torticollis caused by sequelae of poliomyelitis.
