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.

• Inflammation

  The inflammation caused spasms of the prevertebral muscles, eventually leading to torticollis. [ncbi.nlm.nih.gov]

  In adults, poor posture, tumours of the cervical spine, and inflammation of cervical lymph nodes may cause the condition. [britannica.com]

  Possible causes of secondary torticollis include: an acute disc prolapse - the most common cause in adults inflammation of the neck glands infection of the vertebrae cervical spine injury ocular disorders Torticollis can also occur in adults for various [gpnotebook.co.uk]

• Asymptomatic

  It is usually asymptomatic, but in massive infections can cause diarrhea or rectal prolapse. Origin of trichuriasis New Latin Trichūris genus name ( trich(o)- ) (Greek ourā tail ; see ors- in Indo-European roots.) [yourdictionary.com]

  Mild trichuriasis is asymptomatic and delaying treatment until after delivery is an option. [dermnetnz.org]

  Light infections are often asymptomatic; heavy infections may cause abdominal pain, anorexia, diarrhea, and, in children, weight loss, anemia, and rectal prolapse. [msdmanuals.com]

  Late-onset, asymptomatic thoracic scoliosis (8-13 degrees) in CMT also described. 7 Hip dysplasia: 2 to 20% incidence versus 2% in general population. 1 Motor developmental delay and disorders of attention, coordination, language and affect: In a cohort [now.aapmr.org]

  Asymptomatic lesions have been detected in the thoracic spine on routine chest radiographs. ETIOLOGY This is unclear. [gait.aidi.udel.edu]

• Pallor

  On more in-depth evaluation, it was discovered that the child had torticollis, pallor, and brief dizziness or vertigo with each episode. [ncbi.nlm.nih.gov]

  The condition usually is accompanied by vomiting, pallor, irritability, ataxia, and drowsiness. Neurogenic torticollis presents as an acute episode in a child with a previously normal head and neck position. [aafp.org]

  The torticollic episodes (in particular those of shorter duration) may by associated with other symptoms including vomiting, pallor, sweating, apathy or irritability, an unsteady gait, an upwardly-diverted gaze, abnormal truncal posture (tortipelvis) [orpha.net]

• Sudden Infant Death Syndrome

  In 1992, the American Academy of Pediatrics introduced the “Back to Sleep” campaign to reduce the risk Sudden Infant Death Syndrome (SIDS). [childrensupportsolutions.com]

  Most importantly, remember to put your baby down on their back as this reduces the risk of SIDS (Sudden Infant Death Syndrome). When offering your baby food or something to drink, you can always do it on the side which is not favored by the baby. [newkidscenter.com]

  “Many kids have more flattened head shapes today because we want them sleeping on their backs to reduce the risk of sudden infant death syndrome (SIDS),” says Dr. Burke. [health.clevelandclinic.org]

  Plagiocephally is commonly present on the side of the contracted SCM and is related to the contracture and the recommendation of supine sleep positioning for prevention of sudden infant death syndrome. [posna.org]

  This "pseudoepidemic" in torticollis may possibly be due to the Back to Sleep Program to prevent Sudden Infant Death Syndrome. [hss.edu]

• Malaise

  Associated symptoms included headache, nausea, vomiting, and malaise. The patient was initially assessed in a teaching clinic of a university medical health center for acute meningitis. [ncbi.nlm.nih.gov]

  Diagnostic methods Diagnostic criteria include i) recurrent attacks in infants and small children ii) head tilt to either side that remits spontaneously after minutes to days iii) one of the following symptoms: pallor, irritability, malaise, vomiting [orpha.net]

  Suggest cancer, infection, or inflammation: Malaise, fever, unexplained weight loss. Pain that is increasing, is unremitting, or disturbs sleep. [patient.info]

  […] treatment of QTc prolongation and torsade de pointes. torsade de pointes View Full Text Statistics from Altmetric.com torsade de pointes A 41 year old woman was admitted to the accident and emergency (A&E) department with a short history of lethargy and malaise [emj.bmj.com]

• Pneumonia

  Pneumonia presenting with torticollis is exceedingly rare, but seen must often in upper lobe pneumonia. To the best of our knowledge, isolated torticollis in pneumonia without any other symptoms has not been defined. [hindawi.com]

  Bronchitis फेफड़े की सूजन, ब्रोंकाइटिस, ब्रांकाइटिस, श्वसनीशोध, श्वासनली का प्रदाह, Rarely, flu can develop into a high fever, acute bronchitis, encephalitis and pneumonia. [studysite.org]

  […] immobilise in C-spine hard collar and refer to cervical spine trauma Any inflammatory process in the area can cause torticollis, including upper respiratory tract infection, cervical lymphadenitis, dental abscess, retropharyngeal abscess, or upper lobe pneumonia [pch.health.wa.gov.au]

  Fractures Inflammation / Infection Cervical lymphadenitis Retropharyngeal abscess Cervical vertebral osteomyelitis Cervical discitis Rheumatoid arthritis Spontaneous subluxation with adjacent head and neck infection (rotary subluxation syndrome) Upper lobe pneumonia [orthopaedicsone.com]

• Pleural Effusion

  The magnetic resonance images (MRI) of the cervical and thoracic spine, taken in out center, were reevaluated; and necrotizing pneumonia in the left lower lobe of the lung and pleural effusion were revealed (Figure 1(a)). [hindawi.com]

• Persistent Cough

  Case  2 A 6-year-old female was admitted to our facility with persistent cough over the previous month and fever over the previous three days. Additionally, she complained of neck pain for the previous three months without torticollis. [hindawi.com]

• Muscle Rigidity

  When the aggravated vata invades the neck muscles, it causes muscle rigidity, immobility of the neck, and pain in the neck muscles.3 Disclaimer: The information on this page is not intended to be a substitute for professional medical advice. [dabur.com]

• Fracture

  Descriptive case report.To report a rare case of post-traumatic torticollis by odontoid fracture in a patient with diffuse idiopathic skeletal hyperostosis (DISH).Cervical fractures in DISH can result from minor trauma, and a delay in presentation often [ncbi.nlm.nih.gov]

  An ankle fracture occurs when one or more than one bone that makes up the ankle joint—and possibly its ligaments—breaks at or near the joint. Every year, 184 people out of every 100,000 sustain ankle fractures. [northwell.edu]

  More significant trauma may result in subluxation, dislocation or fracture of cervical vertebrae, or fracture of a clavicle If history of significant trauma, immobilise in C-spine hard collar and refer to cervical spine trauma Any inflammatory process [pch.health.wa.gov.au]

  CNS syringomyelia ocular abnormalities, e.g. congenital strabismus/nystagmus Acquired idiopathic musculoskeletal trauma: fracture, facet joint dislocation, muscle spasm fibromatosis colli osteomyelitis juvenile rheumatoid arthritis ligamentous laxity: [radiopaedia.org]

• Myopathy

  Bethlem myopathy MedGen UID: 331805 •Concept ID: C1834674 • Disease or Syndrome Collagen VI-related myopathy is a group of disorders that affect skeletal muscles (which are the muscles used for movement) and connective tissue (which provides strength [ncbi.nlm.nih.gov]

  Still, various causes implicated in the development of congenital muscular torticollis include fibrosis form bleeding during birth, traumatic child delivery, intrauterine crowding, primary myopathies of the sternocleidomastoid muscle, as well as an intrauterine [news-medical.net]

  Neurogenic Myopathy A combination of trauma and ischemia lead to progressive fibrosis, which entraps the SCM branch of the spinal accessory nerve. This nerve compression leads to contracture and deformity. [posna.org]

  […] why some babies are born with a single shortened SCM, they suspect it may be due to one or more of the following factors: Crowding within the uterus during the pregnancy Fibrosis of the muscle from bleeding and/or trauma during childbirth Primary myopathy [verywellhealth.com]

• Morning Stiffness

  […] neck, rarely radiating pain to the shoulder or back, sleeplessness due to pain, morning stiffness etc are the features of this condition. [easyayurveda.com]

• Fussiness

  Your baby may tilt their head to one side Your baby’s head may be misshapen Your baby’s behaviour may become fussy and try to change position of their head. They will not love tummy time. One shoulder may be higher than the other. [monaghanosteopathy.ie]

• Dystonia

  Selective denervation of the neck muscles can directly relieve the spastic dystonia. [symptoma.com]

  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]

  Tremor, myoclonus, focal dystonias, and tics. In: Adams & Victor's Principles of Neurology. New York : McGraw-Hill ; 2009 : 80 – 99. Google Scholar 68. Krauss, JK. Selective Peripheral Denervation for Cervical Dystonia. [doi.org]

  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.medscape.com]

• Headache

  ‘We selected these muscles because they were often involved in stress-related disorders such as tension headache, spasmodic torticollis, and fibromyalgia.’ [oxforddictionaries.com]

  Intermittent torticollis associated with headaches, vomiting, or neurologic symptoms may be caused by tumors of the posterior fossa. Benign and malignant neoplasms of the upper cervical spine are rare causes of torticollis in children. [ncbi.nlm.nih.gov]

  Common symptoms of torticollis include the enlargement of the neck muscles, asymmetry of an infants head from sleeping on the affected side, elevation of the shoulder on the affected side, stiffness of neck muscles, limited range of motion, headaches, [tristatephysicians.com]

• 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]

  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]

  It is also sometimes referred to as wry-neck, stiff-neck, caput obstipum, crooked-neck and twisted-neck. [ncbi.nlm.nih.gov]

  Also known as a wry neck or a ‘crick in the neck’ this is a painful condition of the neck which often happens quite suddenly. The muscles of one side of the neck become stiff and painful and very often it develops overnight. [donegaldaily.com]

  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]

• Agitation

  ‘Because the patient remained extremely psychotic and agitated, IM haloperidol was administered, but this produced a dystonic torticollis.’ [oxforddictionaries.com]

  Antiarrhythmic Dofetilide Tikosyn Antiarrhythmic Droperidol Inapsine Sedative, antiemetic Erythromycin E.E.S., Erythrocin Antibiotic, increase gastrointestinal motility Halofantrine Halfan Antimalarial Haloperidol Haldol Antipsychotic, schizophrenia, agitation [ahajournals.org]

• Cerebellar Ataxia

  Bain PG, O'Brien MD, Keevil SF, Porter DA (1992) Familial periodic cerebellar ataxia: a problem of cerebellar intracellular pH homeostasis. Ann Neurol 31:147–154 CrossRef PubMed Google Scholar 8. [doi.org]

  CAPOS (cerebellar ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss) syndrome is characterized by episodes of ataxic encephalopathy and/or weakness during and after a febrile illness. [ncbi.nlm.nih.gov]

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.

• Cervical Spine X-Ray

  Assessment Investigations If infective or inflammatory thought to be unlikely or if their is a history of trauma, cervical spine X-Rays should be taken Neurological examination should be performed. [pch.health.wa.gov.au]

  To determine the cause of torticollis, our doctors may order upper (cervical) spine X-rays or a CT scan, if there has been an acute fracture. [columbiadoctors.org]

  spine X-ray may detect vertebral anomalies in atypical torticollis A hip US in infants with congenital muscular torticollis is recommended Treatment Educate caregiver on infant positioning during feeding, sleeping and playing (including the importance [rch.org.au]

  You may also need any of the following: Cervical spine x-rays may be done to check for broken bones or other problems in your neck. A CT scan or MRI may be used to look for problems in your bones, muscles, brain, and blood vessels. [drugs.com]

• Staphylococcus Aureus

  Increase in community-acquired methicillin-resistant Staphylococcus aureus in children, Clin Infect Dis 1999;29:935-936. 14. Gottlieb RD, Shah MK, Perlman DC, Kimmelman CP. [arastirmax.com]

  Lemierre-like syndrome caused by community-associated methicillin-resistant Staphylococcus aureus complicated by hemorrhagic pericarditis. Pediatr Crit Care Med. 2010;11(3):e32-5. Marion MH, Humberstone M, Grunewald R, Wimalaratna S. [cancercarewny.com]

  Teicoplanin and ceftriaxone were initiated, after transthoracic aspiration, and methicillin resistant Staphylococcus aureus was grown. [hindawi.com]

  The most common causative organisms include Staphylococcus aureus and Mycobacterium tuberculosis. Intervertebral disk and bone destruction is common with both pyogenic and tuberculous osteomyelitis (34). [pubs.rsna.org]

• Pleural Effusion

  The magnetic resonance images (MRI) of the cervical and thoracic spine, taken in out center, were reevaluated; and necrotizing pneumonia in the left lower lobe of the lung and pleural effusion were revealed (Figure 1(a)). [hindawi.com]

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].

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.

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.

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].

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.

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.

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.

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.

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