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Torticollis

Torticollis is a medical condition described as a twisted neck where the head is tipped to one side while the chin is pointed towards the opposite side. Torticollis is also referred to as cervical dystonia characterized by the involuntary tonic contractions or spasm of the neck muscles.


Presentation

The abnormal neck contractions associated with torticollis can cause the head to turn or twist to a variety of orientation and directions. Some patients may have a combination of two or more presentation. The following directions are noted in cervical dystonia:

  • Chin towards the shoulder (most common)
  • Chin straight up
  • Chin straight down
  • Ear towards the shoulder

A number of patients may present with involuntary neck jerking and neck pain that radiates to the shoulders which are often times referred to as disabling in character.

Cervical Lymphadenopathy
  • Cervical lymphadenopathy due to infection or cancer. Vertebral infection (eg, osteomyelitis ). Cervical spine injury (eg, post-traumatic fracture or dislocation). Eye disorders.[patient.info]
  • High-resolution and color Doppler ultrasonography of cervical lymphadenopathy in children. Acta Radiol 2001 ;42(5): 470–476. Crossref, Medline, Google Scholar 29 Craig FW, Schunk JE.[pubs.rsna.org]
Dystonia
  • Idiopathic spasmodic torticollis occurs more frequently in females, and onset typically occurs in those aged 30-60 years. [27] Pediatric central etiology dystonias include torsion dystonia, drug-induced dystonia, and cerebral palsy. [28] Epidemiology[emedicine.com]
  • Selective denervation of the neck muscles can directly relieve the spastic dystonia.[symptoma.com]
  • Deep brain stimulation for primary generalized dystonia: long-term outcomes. Arch Neurol. 2009 ;66: 465 – 470. Google Scholar Crossref Medline 95. Krauss, JK, Loher, TJ, Pohle, T.[doi.org]
  • Women are more likely to develop cervical dystonia than are men. Family history. If a close family member has cervical dystonia or some other type of dystonia, you are at higher risk of developing the disorder.[mayoclinic.org]
Neck Stiffness
  • Convert to ICD-10-CM : 723.5 converts directly to: 2015/16 ICD-10-CM M43.6 Torticollis Approximate Synonyms Neck stiffness Sandifer syndrome Stiff neck Stiffness of neck Torticollis Clinical Information A symptom, not a disease, of a twisted neck.[icd9data.com]
  • It is also sometimes referred to as wry-neck, stiff-neck, caput obstipum, crooked-neck and twisted-neck.[ncbi.nlm.nih.gov]
  • If you or your pediatrician notice the neck stiffness and irregular head tilt that can point to torticollis in infants, schedule an evaluation with a specialist as soon as possible.[gillettechildrens.org]
  • Complications of torticollis include neck deformity and constant neck stiffness and pain. This constant tension may result in muscle swelling and neurological symptoms due to pressure on the nerve roots.[emedicinehealth.com]
Babinski Sign
  • Upper motor neuron signs in the lower limbs (Babinski's sign: upgoing plantar reflex, hyperreflexia, clonus, spasticity). Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia).[patient.info]
Clonus
  • Upper motor neuron signs in the lower limbs (Babinski's sign: upgoing plantar reflex, hyperreflexia, clonus, spasticity). Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia).[patient.info]
Cervical Radiculopathy
  • Cervical radiculopathy Cervical radiculopathy is usually due to compression or injury to a nerve root in the cervical spine, which may present as pain, motor dysfunction, sensory deficits, or alteration in tendon reflexes.[patient.info]

Workup

The diagnosis of torticollis is easily achieved by simple physical examination of the neck. Ancillary tests are also used to determine the underlying causes of the neck pathology. These tests include:
Blood tests – the serum from the blood can show acute phase reactants and the presence of toxins.
Urine tests – certain toxins can easily be monitored in the urine.
Magnetic Resonance Imaging (MRI) – this imaging technique can demonstrate the presence of tumors and any evidences of brain ischemia in stroke.
Electromyography (EMG) – This diagnostic modality identifies the electrical impulses in the muscles helping physicians to evaluate any muscular and nerve disorders.

Treatment

There are no definitive cure for torticollis. In some cases, the signs and symptoms may resolve without treatment but may also recur. The goal in the management of torticollis focuses on relieving the symptomatology of the disease process. The following treatment modalities are available for torticollis:
Botulinum toxin – These bacterial toxin is directly injected on the dystonic muscle of the neck to paralyze it. The botulinum toxin is given in intervals of 3 to 4 months [8].
Muscle relaxants – Medications like diazepam, lorazepam, and baclofen are given to relieve the spasms in muscles.
Pain relievers – Oral pain killers are given to relieve the persistent pain caused by the spastic contractions of the muscles.
Parkinsnon’s drugs – These drugs are given with botulinum toxin to enhance the relaxation effects on muscles.
Physical therapy – This non-surgical approach focuses on exercises that strengthens the neck muscles and make it more flexible [9].
Neck Bracing – The use of this orthotic device can limit the twisting of the neck among patients with torticollis
Selective denervation – This surgical intervention cuts off the nerves from the affected muscles to paralyze the spastic muscles [10].

Prognosis

There are no eminent deaths related to torticollis. Afflicted patients enjoy a comparable life expectancy rate with the normal individuals. Morbidity with torticollis relates to the abnormal posturing adopted by the patient to compensate to the neck spasm, the development of spondyloses of the cervical spine due to chronic dystonia, and the social stigmata that results in isolation and major depression. Up to 90% of patients suffering from congenital torticollis responds well with physical therapy. Patients promptly subjected to selective denervation procedures experience a high satisfactory rating.

Etiology

The majority of cases of torticollis is classified as idiopathic or with no known cause [1]. Some cases are linked with head and neck trauma that results in the damage of the upper cervical spine, muscles, and nervous system. Studies have postulated that genetic transmission is possible for torticollis or spasmodic dystonia of the neck. Torticollis is also linked to infections, tumors, and scar tissue formation in the surrounding neck tissues. The serious infection in retropharyngeal abscess is closely associated with torticollis [2]. This neck condition may be associated with the dystonic reaction of the body to medications like metoclopramide, haloperidol, phenothiazine, carbamazepine, phenytoin, and L-dopa.

Epidemiology

Only 10-20% of torticollis results from trauma while the majority of cases are usually idiopathic in nature. Prospective studies results reveal that most cases of torticollis usually exists as mixture of distinct movements [3]. Females are affected more than twice compared to the male counterpart [4]. There are no racial predilection to the prevalence of torticollis. The relative onset of the acute type of cervical dystonia or torticollis occurs within a few days from neck trauma while the delayed forms appear within 3 to 12 months from actual injury. Congenital cervical torticollis occurs among the newborns with a relative incidence rate of 4 cases per 1000 newborns [5].

Sex distribution
Age distribution

Pathophysiology

The most common pathogenesis involved in congenital torticollis is the intrauterine trauma to the sternocleidomastoid muscle of the neck that causes local fibrosis and a consequent unilateral shortening of the one side of the neck [6]. Congenital torticollis usually results from a traumatic delivery like breech and forceps delivery [7]. For post-traumatic torticollis, an initial inciting trauma to the cervical muscular tissues and the cranial nerve initiates the neck pathology. Acute torticollis that results from the idiosyncratic reaction of the body to the drugs like phenytoin, metoclopramide, and carbamazepine may resolve spontaneously without treatment.

Prevention

The early identification of the disease and early intervention can prevent further complications in torticollis. Parturient mothers with high risk of difficult delivery should deliver the infant in the nearest tertiary hospital to prevent dystocia and damage to the infant’s neck muscle during the difficult delivery.

Summary

Torticollis is clinically defined as a painful condition of the neck muscles wherein they involuntarily contract causing the head to turn to one side. In some cases of spasmodic torticollis, the head may tilt forward and backward uncontrollably. This rare neck disorder can occur at any age, although it commonly occurs among middle aged people. There is no definitive cure for torticollis. Some cases resolve spontaneously without intervention. The use of botulinum toxin may temporarily allay the signs and symptoms of torticollis when injected on the affected muscles.

Patient Information

Definition: Torticollis is clinically defined as a painful condition of the neck muscles wherein they involuntarily contract causing the head to turn to one side giving a twisted neck appearance.
Cause: Majority of torticollis has an unknown etiology. Some cases are triggered by trauma and intake of medications like metoclopramide, carbamazepine, and phenytoin. Intrauterine trauma to the neck tissue are associated with congenital torticollis.
Symptoms: Patients will present clinically with the twisting of the neck muscles toward a number of directions with some pain.
Diagnosis: Torticollis is diagnosed clinically through a meticulous physical examination. Blood tests, urine test, imaging studies, and EMG are ancillary tests that have some medical importance in the diagnosis of torticollis.
Treatment and follow-up: Patients with torticollis are treated with botulinum toxins injected on the spastic muscles. Selective denervation of the neck muscles can directly relieve the spastic dystonia.

References

Article

  1. Sanuki T, Isshiki N. Outcomes of type II thyroplasty for adductor spasmodic dysphonia: analysis of revision and unsatisfactory cases. Acta Otolaryngol. Nov 2009; 129(11):1287-93.
  2. Hasegawa J, Tateda M, Hidaka H, et al. Retropharyngeal abscess complicated with torticollis: case report and review of the literature. Tohoku J Exp Med. Sep 2007; 213(1):99-104.
  3. Consky EA, Lang AE. Clinical assessments of patients with cervical dystonia. In: Jankovic J, Hallett M, eds. Therapy with Botulinum Toxin. 1994. New York: Marcel Dekker; 211-237.
  4. Jankovic J, Tsui J, Bergeron C. Prevalence of cervical dystonia and spasmodic torticollis in the United States general population. Parkinsonism Relat Disord. Oct 2007; 13(7):411-6.
  5. Canale ST. Congenital muscular torticollis. In: Canale ST, Daugherty K, Jones L eds. Campbell's Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby-Year Book; 1998:1064-7.
  6. Robin NH. Congenital muscular torticollis. Pediatr Rev. Oct 1996; 17(10):374-5.
  7. Jankovic J. Can peripheral trauma induce dystonia and other movement disorders? Yes! Mov Disord. Jan 2001; 16(1):7-12.
  8. Oleszek JL, Chang N, Apkon SD, Wilson PE. Botulinum toxin type a in the treatment of children with congenital muscular torticollis. Am J Phys Med Rehabil. Oct 2005; 84(10):813-6.
  9. Petronic I, Brdar R, Cirovic D, et al. Congenital muscular torticollis in children: distribution, treatment duration and outcome. Eur J Phys Rehabil Med. Dec 15 2009.
  10. Bertrand C, Molina-Negro P, Bouvier G, Gorczyca W. Observations and analysis of results in 131 cases of spasmodic torticollis after selective denervation. Appl Neurophysiol. 1987; 50(1-6):319-23.

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Last updated: 2019-07-11 22:31