TORTICOLLIS - SIGNS, SYMPTOMS & COMPLICATIONS

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The word torticollis is derived from Latin and literally means ‘twisted neck’; it is commonly called ‘wry neck’, spasmodic torticollis or cervical dystonia. To put it correctly, torticollis refers to presentation of the neck in a twisted or bent position. Spasmodic torticollis is a form of dystonia. There are various types of dystonia, identified by where they occur in the body and what causes them. Dystonias involving only one limb or body part are referred to as focal. Spasmodic torticollis is therefore, a form of focal dystonia.

From a clinical point of view, torticollis is both a symptom and a disease. As a symptom, it manifests in involuntary contractions of the neck muscles (the sternocleidomastoid), leading to abnormal postures and movements of the head. As a disease, it may be divided into 2 types: congenital torticollis and acquired torticollis.

Congenital torticollis is a rare condition. A baby with congenital torticollis appears healthy at birth but over the next couple of days to weeks, they develop a soft tissue swelling over an injured sternocleidomastoid (which is usually the very first sign of congenital muscular torticollis). In time this mass regresses to leave a fibrous band in the place of the sternocleidomastoid muscle and resulting in spasm of the neck. Although the exact cause of congenital torticollis is unknown, it has been suggested that intrauterine malpositions and injuries occurring during childbirth might play a role in its development. Spasm of the neck muscles seen in congenital torticollis is also associated with other conditions such as hip dysplasia, irregular facial features and abnormalities in the bones of the neck (cervical vertebrae).

Torticollis becomes acquired when it develops in a previously healthy child. In acquired torticollis, the head is almost always tilted away from the muscles in spasm unlike in congenital torticollis where the baby prefers to tilt the head almost always toward the spasm.

Acquired torticollis could be primary or secondary. Primary spasmodic torticollis is one that occurs without any identifiable cause and its development has been link to inheritance of a defective gene.

Secondary spasmodic torticollis could occur from any of the following conditions -

    • Infections including cervical osteomyelitis, retropharyngeal space infection; these infections usually result in irritation of the nerves supplying the muscles of the neck producing torticollis. Acquired torticollis could also be the result of ear infections.
    • Tumours – of the base of the skull (posterior fossa tumours) which can compress the nerve supply to the neck, resulting in torticollis.
    • Trauma to the neck – including occipital condyle fractures, cervical muscle spasm following motor vehicle accident and odontoid fractures may stimulate torticollis. Trauma in the neck could result in atlantoaxial rotatory subluxation (partial dislocation), in which the two vertebrae closest to the base of the skull slide with respect to each other tearing stabilizing ligaments. The atlas is the name given to the first cervical vertebrae and the axis is the name given to the second cervical vertebrae.
    • Cervical disk disease – Subluxation and or herniation may cause deviation to one side.
    • Drug-induced torticollis – Certain drugs such as ketamine, amphetamines, cocaine and commonly prescribed neuroleptics including prochlorperazine, haloperidol, and chlorpromazine can cause acute dystonia (a lack of normal muscle control). Acute dystonia is a condition that involves the sudden onset of involuntary contractions of the muscles of the face, neck or back.
    • Ocular condition – Patients with palsy of the inferior oblique muscle hold their heads at an angle to correct visual disturbances.
    • Other rare causes.

Signs and Symptoms of torticollis include:

    • Anterocollis – abnormal forward tilting of the head.
    • Retrocollis – abnormal backward tilting of the head.
    • Laterocollis – abnormal sideways tilting of the head.
    • Enlargement of the neck muscles.
    • Unevenness in the shape of a baby’s head from sleeping on the affected side.
    • Elevation of the shoulder on the affected side.
    • Stiffness in the neck muscles.
    • Limitation in the normal range of motion.
    • Headache.
    • Neck pain.
    • Tremors.

Complications of torticollis:

    • Nerve compression in the neck could produce tingling sensations in the upper extremity or may lead to permanent nerve damage.
    • Torticollis could lead to permanent physical deformities.
    • In congenital torticollis, the base of the skull may become deformed.
    • Some children may later on develop uneven facial features.

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