TORTICOLLIS

Definition Tortous = twist collum = neckCongenital Muscular TORTICOLLIS (CMT) is :unilateral contracture of sterno.cleido-mastoid muscle (s.c.m.)the head tilted toward the contracture side the chin rotated toward the opposite sidehead and face : asymmetric deformity

EtiologyFibrosis s.c.m. contracture, shortens fail to elongate as the child grows progressive deformityCause of fibrosis?local ischaemia : distorted position in uterobirth history : breech, forcipal deliverynote : sectio caesaria : CMT (+)compartment syndrome of s.c.m.75% R-sideCMT with DDH = 1 in 5 CMT (Hummer & Mc Ewen)20% with lump (tumor)

PathologyLump : dense fibrous tissue no hemorrhage or hemosiderineMuscle : replaced by fibrous tissue

Clinical findingsDeformity :torticollis may present at birthor (2-3) weeks ageHead tilted to the contracted muscle Chin rotated to opposite side Eyes-shoulder lines : not parallel

Clinical findingsLump :Appear at (2-3) weeksSlowly regress in (6-12) weeks after which the torticollis become apparent Face and head face flattened by external pressure-plagycephally, related to the sleeping position prevention : not to sleep in prone positionby growth : face asymmetry increaseNeck (posterior view)Scoliosis lower C-upper D

Sternocleidomastoid muscle mass in muscular torticollis.The mass develops in early infancy and disappears spontaneously over a period of several months

If deformity is not corrected (adolescent, adult)asymmetry face & head increase scoliosis increasesoft tissue :s.c.m. : shorteningdeep cervical fascia : thicker, contractedscalenus ant and medius : shortenedcarotid sheath : contracted

Differential Diagnosis of CMT1. Congenital Anomalies :postural toricollishemivertebrae, cervical-superior dorsal spineunilateral atlanto-occipital fusionKlippel-Feil syndromeunilateral cong.absence of s.c.m.Pterygium colli 2. Trauma : mainly C1,C2, rotatory subluxation, fracture 3. Inflammatory conditions-unilateralCervical lymphadenitisCervical spine infection = tb, pyogenicRheumatoid arthritis (Juvenile)Spontaneous hyperaemic subluxation of the atlas

Differential Diagnosis of CMT4. Neurlogic disordersVisual disturbanceSyringomyeliaSpinal cord tumorBrain tumor : posterior fossa5. Acute calcification of cervical disc6. Tumor of s.c.m. :Cystic hygroma, branchial cleft cyst, thyroid teratoma 7. Skeletal dysplacia, Morquio syndrome, spondyloepi-physeal dysplacia, Down s syndrome associated with C1-2 instability 8. Psychosomatic (hysterical,psyhogenic causes)

TreatmentConservative :manipulationpassive stretchingeach stretching halted for 10 seconds (15-20) xa day (4-6) xby physiotherapist or by parentsresult (85-90)% successOperative + 10% fail by stretchingAge > 1 yearrecurrentTechnic :unipolarbipolar1874 : William Cheseldon : tenotomy s.c.m.

Operative technic :1 case monopolar (Z plasty)14 cases : bipolarPostoperative :Glisson tractionSand pillows lateral of the headDiazepam2 days after surgery : stretching [7 days after surgery : stitches off]Collar, 1 cm elevated on the affected side. To be used for 3 monthsContinue stretching programme

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