Congenital Muscular Torticollis By: Paula Maye G.

Bernabe Definition: Congenital muscular torticollis is a painless condition usually presenting during infancy with a tight sternocleidomastoid muscle causing the child's head to be tilted to the tightened side. Limited neck motion and a palpable tumor within the muscle are often present. A regimen of stretching exercises is the most common form of treatment with positive outcomes for over 90% of the identified cases. Rarely children require surgical intervention to release the tightened muscle. Botox injections to relax the tight muscle is a new form of treatment being used by some practitioners. Torticollis also presents as a symptom for a variety of muscular, bony, and neurologic conditions. Congenital muscular torticollis (CMT) is a postural deformity detected at birth or shortly after birth, primarily resulting from unilateral shortening and fibrosis of the sternocleidomastoid muscle (SCM). CMT is estimated to occur in one infant of every 300 live births. Plagiocephaly is reported as a coexisting impairment in 80% to 90.1% of children with CMT. Alternative Names: Wry neck, Loxia Etiology: What causes congenital muscular torticollis? It is traditionally thought to be due to trauma at birth, that causes bleeding in the muscles of the neck, usually the Sternomastoid muscle. The hematoma (blood clot) within the muscle scars down over time, causing the muscle to shorten, thus pulling the head to the typical tilted position. Sometimes, there is an associated mass that can be seen or felt within the Sternomastoid muscle, and usually thought to be a hematoma that is in the process of forming scar tissue. This mass usually disappears by 3 months of age. More recently, it has been postulated that the sternomastoid muscle shortens as a result of scarring due to an intrauterine vascular disturbance. Still others think that it is due to intrauterine position of the head causing fibrosis or shortening of the muscle. Signs and Symptoms:

Limited range of motion of the head Headache Head tremor Neck pain Shoulder is higher on one side of the body Stiffness of neck muscles Swelling of the neck muscles (possibly present at birth)

Anatomy and Physiology

Pathophysiology Congenital muscular torticollis

caused by local trauma to the soft tissues of the neck just before or during delivery

birth trauma

Results hematoma formation

Causing muscular contracture

Those undergone breech

difficult forceps delivery

fibrosis in the muscle may be due to venous occlusion and pressure on the neck in the birth canal because of cervical and skull position

Types: Torticollis is classified into:

Congenital Muscular Torticollis present at birth and the most common form. Acquired Torticollis acquired later in life

Treatment: a. Surgical: Various tests or procedures may be done to rule out possible causes of head and neck pain. A physical examination will show a visible shortening of the neck muscles and the head will tilt toward the affected side while the chin points to the opposite side. In more severe cases, the entire head pulls and turns to one side A electromyogram (EMG) may be done in mild cases to see which muscles are most affected. Treatment of congenital torticollis involves stretching the shortened neck muscle. Passive stretching and positioning are treatments used in infants and small children. Such treatments are often successful, especially if started within 3 months of birth. Surgery to correct the neck muscle may be done in the preschool years, if other treatment methods fail. Acquired torticollis is treated by identifying the underlying cause of the disorder. Application of heat, traction to the cervical spine, and massage may help relieve head and neck pain. Stretching exercises and neck braces may help with muscle spasms. b. Medical: Medications used to treat this condition include an anticholinergic drug called baclofen. Injection of botulinum toxin can temporarily relieve the torticollis, but repeat injections every 3 months are usually needed. Surgery is rarely used. Diagnostic Test: 1st tests to orders Test CervicalSspine X-ray Should be obtained routinely at initial visit to rule out vertebral anomalies. Pelvic X-ray Should be obtained routinely to screen for hip dysplasia. Diagnostic Result negative in congenital muscular torticollis negative in congenital muscular

value of x-rays in children under 4 months is limited due to poor ossification of the femoral head. HipUltrasound Should be obtained routinely if younger than 4 months. Tests to considershow all Test Neck ultrasound Pathognomonic but not routinely done. Skull X-ray Should be obtained if cranial asymmetry is not typical of that seen in congenital muscular torticollis. Cervical/Cranial MRi To rule out posterior fossa or spinal cord tumour.

torticollis negative in congenital muscular torticollis

Result sternocleidomastoid fibromatosis coli negative in congenital muscular torticollis negative in congenital muscular torticollis

Nursing Management: Congenital Torticollis

Passive stretching exercises and encouraging the infant to look at the affected muscle (by feeding at the direction of the affected area and positioning mobiles on the injured part). If simple exercises are not effective, a surgical correction is done. This is followed by usage of neck immobilizer to further correct the deformity.

Acquired Torticollis

Identification of underlying cause of the disorder. Heat application for head and neck pain Cervical spine traction Neck massage Anticholihergic drugs Use of Botulism (Botox)

Complications: Complications may include:

Muscle swelling due to constant tension Neurological symptoms due to compressed nerve roots