Torticollis in Infants and Children: A Common Etiology for Flat Head

What Is Torticollis?

Torticollis is a condition in infants where the tight neck muscles cause the head to twist or tilt to one side. In two percent of infants, the condition is found. The top of the head is tilted to one side, whereas the chin is to the other. Consequently, the baby's neck is turned at an abnormal angle. Wry neck, another ailment, is common in young children and newborns.

Torticollis can be congenital or acquired. Congenital torticollis are common and painless in infants. When the infant is a few weeks old and has developed improved head control, the problem can be identified. Shortening of one of the sternocleidomastoid muscles in babies causes congenital torticollis. The cause for muscle shortening remains unknown.

Acquired torticollis develops within the first four to six months of an infant’s life or later. The symptoms may appear suddenly or develop gradually. Acquired torticollis can be a harmless condition or might indicate a health concern.

In rare instances, infants with torticollis can develop other conditions like developmental dysplasia of the hip, metatarsus adductus (front part of child foot turn inwards), talipes equinovarus (club foot), and C1 to C2 subluxation (abnormal rotation).

Why Does Torticollis Develop?

Torticollis in infants and children can develop due to musculoskeletal or non-musculoskeletal pathology. According to a few theories, the causes of congenital torticollis are:

• If the baby’s head is tilted to the side and down, the blood supply to the neck muscle decreases. Prolonged periods in this position cause stiffening in the baby’s neck muscles.

• Difficult childbirth causes trauma and injury to the neck muscle.

• Utilizing forceps or a vacuum during childbirth.

• Sternocleidomastoid muscle growth anomaly.

• Developing hematoma (localized bleeding) in the baby's neck muscle.

• Baby's muscular tissue fibrosis.

• Klippel-Feil syndrome.

• Congenital bone anomaly in the upper cervical spine, including aberrant rotation of the C1 vertebrae over the C2 vertebrae.

• Congenital bony abnormality in the upper cervical spine is associated with congenital skeletal abnormalities like shortened neck, short limbs, and dwarfism.

• Congenital skin webs that run alongside the side of the neck.

• Achondroplasia (bone growth disorder).

• Multiple epiphyseal dysplasia (disease affecting bone and cartilage development in long bones of arm and leg).

• Morquio’s syndrome (metabolic disorder).

Acquired torticollis are caused by swelling within the child’s throat. Swelling causes the tissues surrounding the upper spine to loosen. Therefore, the vertebrae dislodge from the normal position, causing the neck muscle to spasm and the head to dislodge to one side. The causes for developing acquired torticollis are:

• Infection (viral).

• Minor injury to head and neck.

• Gastroesophageal reflux disease (GERD).

• Eye problem.

• Reaction to medications.

• Arthritis.

• Cervical spondylitis.

• Sandifer syndrome (a disorder of gastroesophageal reflux and neck spasm).

• Grisel’s syndrome (non-traumatic subluxation of neck vertebrae).

• Respiratory and soft tissue infection of the neck.

• Abnormalities in the cervical spine.

• Spasmus nutans (head bobbing and uncontrolled eye movements).

What Are the Signs and Symptoms of Torticollis?

Congenital Torticollis

• Baby’s head tilts to one side towards the tight neck, whereas the chin is to the other.

• Limited neck and head movement in the infant.

• One side of the baby's shoulder appears higher than the other.

• Neck muscles become tight and stiff.

• Swelling in neck muscles.

• Pea-sized swelling develops within the neck muscle.

• Asymmetrical facial features.

• Have trouble breastfeeding on one side.

Acquired Torticollis

In addition to congenital torticollis symptoms, the child develops the following symptoms:

• Severe neck pain.

• Head tremors.

• Headache.

• No facial symmetry.

How to Diagnose Torticollis?

1. The diagnosis might be aided by a physical examination to determine whether the infant's head is twisted or tilted.

2. Additionally, the neck muscles are checked for any enlargement or rigidity.

3. The doctors can recommend a neck X-ray, head and neck CT (computed tomography), or MRI (magnetic resonance imaging) to confirm the diagnosis.

What Is the Treatment for Torticollis?

Stretching exercises and positional modifications can typically correct congenital torticollis. Neck stretching helps loosen the tight sternocleidomastoid muscle and strengthens the other underused muscle. The infant's head needs to be softly shifted to the alternative side. The exercises must be repeated several times a day, gradually increasing movements. Position changes are achieved by placing the baby on their back and positioning the baby’s neck on the opposite side during naps and bedtime. Toys and things are moved about while the infant is awake so that the baby can practice turning their neck in the opposite direction. The improvements can become noticeable within a few months.

Doctors can refer the baby to a physiotherapist for further treatment. After the treatment begins, the doctor examines the baby every four to six weeks to assess improvement in torticollis. If the treatment does not work, specialist intervention is required. Surgery may be necessary to lengthen the short sternocleidomastoid muscle.

Antibiotics treat the infectious causes of acquired torticollis, while botulinum toxin injections cure tense neck muscles. In addition, treatment with heat therapy, massage, neck braces, and physical therapy are needed.

Although torticollis cannot be prevented, early treatment can stop it from getting worse and necessitating surgery. Most babies show improvement in torticollis within six months of initiating stretching exercises and position changes. However, a few babies may take a year or longer.

How Do Parents Help in the Treatment of Torticollis?

Parents can encourage the baby to turn their head in both directions. Some exercises that parents can try at home are:

• While eating or breastfeeding the baby, encourage them to turn away from the favored side.

• Put the baby to sleep by positioning them to face the wall. Babies often turn away from the wall to stretch their tense neck muscles because they like to look outside the room.

• Drawing the baby’s attention with toys and sounds will make them look in both directions.

• During wake times, it is crucial to lay babies on their stomachs briefly. These help strengthen the baby’s neck and shoulder muscles and help them to crawl.

What Are the Complications of Torticollis?

The child's face becomes deformed due to a lack of muscle movement. Another complication is plagiocephaly (flat head syndrome). An infant's head is flat and moldable. When the infant is affected by torticollis, they rest the same section of the head that flattens due to pressure.

Conclusion

Torticollis is a clinical presentation with the head tilted to the lateral side and the chin tilted towards the opposite. Several factors cause the development of torticollis in infants and children. Early intervention with exercise and position changes can prevent symptoms from worsening. Rarely, surgical approaches may be needed for torticollis correction.