An Osteopathic

Approach to Torticollis,
Plagiocephaly, and
Online PPT 2/9&12/15
Otitis
Media
Angela Branda,
DO

Objectives
Review and Define common pediatric presentations: Plagiocephaly,
Torticollis, and Otitis Media

Explain the anatomy behind these problems, and why they are
commonly seen in Pediatrics

Review current diagnosis and treatment of these problems

Identify common Osteopathic strains and considerations within

these presentations

Explain how the incorporation of OMT can best be used in the

treatment of these conditions

Torticollis
Definition - a malposition of the neck where the
neck is sidebent in one direction and the head is
rotated in the other
This is acutally a sign rather than a disease itself,
and can be caused by many things

Typically it involves
spasm of the
sternocleidomastoid,
though it can involve
the scalenes as well
(which then causes rib
dysfunctions)

Soo, we may have caused it

a little..
1992 APA Back to Sleep program recommendation that
babies only be placed on their backs when being put to sleep
Decreased incidence of Sudden Infant Death Syndrome (SIDS)
by 40%
Increased incidence of Plagiocephaly 6-fold
Increased incicence of Congenital Muscular Torticollis (CMT) by
84%
Note CMT is defined as torticollis that develops within the first
8 weeks of life, and may not be evident at birth

Often pts sleeping on their backs will have a tendency to

turn their head to the same side, resulting in tightening of
the opposite SCM, and pressure on one part of the skull
repeatedly
However, these problems are reversible, whereas SIDS is
not, so the recommendation is still important!!! It just
requires more education on ways to prevent these other
problems (see more below)

What else can cause

Toricollis?

Congenital

Muscular torticollis
Positional deformation
Hemivertebra (cervical
spine)
Unilateral atlanto-occipital
fusion
Klippel-Feil syndrome
Unilateral absence of SCM
Pterygium colli

Neurologic
Visual disturbances (nystagmus,
superior oblique paresis)
Dystonic drug reactions
(phenothiazines, haloperidol,
metoclopramide)
Cervical cord tumor
Posterior fossa brain tumor
Syringomyelia
Wilson disease
Dystonia musculorum deformans
Spasmus nutans

Trauma
Muscular injury (cervical muscles)
Atlanto-occipital subluxation
Atlantoaxial subluxation
C2-3 subluxation
Rotary subluxation
Fractures

Inflammation
Cervical lymphadenitis
Retropharyngeal abscess
Cervical vertebral osteomyelitis
Rheumatoid arthritis
Spontaneous (hyperemia, edema)
subluxation with adjacent head and neck
infection (rotary subluxation syndrome)
Upper lobe pneumonia

Other
Acute cervical disk calcification
Sandifer syndrome (gastroesophageal
reflux, hiatal hernia)
Benign paroxysmal torticollis
Bone tumors (eosinophilic granuloma)
Soft tissue tumor

CMT with SCM

Tumor:
Pseudotumor of Infancy

Aka: Fibromatosis Colli

Fibrotic muscular
tumor of the SCM

Myoblasts, fibroblasts,
mesenchymal cells

General fibrosis and

thickening of SCM

Can progress to
complete fibrosis and
contracture of SCM if
left untreated

What do we do for it?

Treatment of Torticollis is multifactorial

If there is an underlying cause other than muscle

spasm, that obviously needs to be addressed (see
above HUGE differential list)

Identifying cranial strains (commonly the cranial

base, occiput/condyles) is important as this may
be a primary cause

Testing of both SCM and scalenes and treatment of

both as needed, as well as interplay of any
cervical/rib/thoracic inlet/thorax strains as all of
these can affect the muscles at their attachments

What can parents do?

Education of the parents is key, as often these issues

are related to positioning at rest

Encouraging supervised tummy time (once baby is old

enough around 3 months) to strengthen extensors
and reduce time spent turned to one side

Placement of mobiles/mirrors/etc on other side of the

crib to encourage looking the other way when
sleeping (cushions and pillows in the crib are not
recommended as they are a suffocation risk)

Play time in which toys and sounds are used to

encourage baby to turn their head to the opposite
direction

VERY GENTLE stretching at home

Plagiocephaly

Definition - abnormal shape/deformity of the skull

Can be differentiated into primary and secondary

Primary plagiocephaly - skull deformation due to

intrauterine lie or as a result of the forces of labor or
delivery. It can be noticed from birth or soon after.
Secondary plagiocephaly - develops secondary to
forces from a torticollis or persistent abnormal
posturing. Not usually noticed until the infant is
several months old

MUST be on the lookout for Craniosynostosis!!!

Craniosynostosis

Craniosynostosis is a premature fusion of the cranial sutures

resulting in abnormal head shape that has features that are
decidedly different from that of plagiocephaly

It can be part of a genetic syndrome, in which several other

features of that syndrome are present

Can be non-syndromic which usually only involves one

suture line and is related to mechanical forces (abnormal
stretch forces signaling premature ossification

Most common suture involved is the Saggital Suture

(scaphocephaly)

Growth along that suture line will cease, but growth of the
non-fused areas will continue, resulting in significant
deformity of the skull

How will I know?

Signs that make you worry about craniosynostosis

rather than simple plagiocephaly:

Slowed growth of head circumference (may stop

completely)
Palpable bony ridge along fused suture line
Worsening of the deformity
Developmental delay
Abnormal hair growth pattern

Recommended CT for evaluation (this condition is

very serious and worth the radiation but need a
high suspicion to go for it)

Treatment is surgical (and usually looks really

drastic!!)

Plagiocephaly
Parallelogram

Synostosis
Trapezoid

Growth throughout not restricted,

just shifted. Will still have growth
along all suture lines.

Growth across fused suture

halted, with narrowing of that
line and exaggeration along all

Plagiocephaly vs.
Craniosynostosis
saggit
al

Parallelogram with some

frontal bossing, but no
restriction of growth along
sutures

Restriction along growth of suture listed

with pic

coronal

Metopi

Okay, its just

Plagiocephaly..Now
what?
Causes of plagiocephaly
are varried. Pts subjected to

abnormal forces in utero, torticollis, trauma, consistent back

sleeping, prolonged time in car seats without changing
position, limited tummy time are all factors that can play
into plagiocephaly.

Treating the patient first involves identifying reversible

causes and educating parents on ways to help at home

Having pts change position more often (back-to-sleep still

recommended for reduction of SIDS), more tummy time,
playing with baby to make them turn their head to the other
side (or putting toys on the other side of the crib to make them
turn)
Many of the positional issues used for treatment of torticollis
are also used in plagiocephaly, as the two are often
interrelated.

More fun with

Treatment

Severe/Unresolving Plagiocephaly may require

helmet therapy

Pt is fitted for a helmet that places gentle pressure

on areas with bossing while creating space over
flattened areas for them to expand
As the pts head grows, it will idealy develp into
the areas with space, resolving the flattening
Helmets are not static, and are modified regularly
as the pts head changes
Can result in pressure sores (though they are
much softer than you might think)

Where does OMT fit in?

As underlying cranial strains can lead to plagiocephaly,

addressing these early can allow for faster resolution

Plagiocephaly that develops due to position can cause further

craniosacral strains, and prevent resolution or cause other
problems, and need to be addressed

Other mechanical causes, such as torticollis causing a

positioning issue are easily addressed with treatment

BLT, BMT, soft tissue, myofascial unwinding are all very

effective treatments no specific thing to treat identify each
patients strains and address them to optimize movement

Pts receiving helmet therapy still should be treated with OMT

they work well in conjunction with one-another (ideally
helmet adjustments will happen after a treatment to promote
growth when the recent strains have been released)

Suggested
Protocol

If no change in shape with OMT,

PT, and positioning by 4-8 weeks

Obtain x-rays of sutures

Obtain 3D CT of head

If x-rays of sutures are poorly

visualized

If sutures are patent begin head

orthosis (helmet) treatment
(best if initiated b/w 4 - 6
months of age)

NOTE: 85% of post-natal growth

happens in 1st year of life; 10%
of PHD children will have
cosmetic fascial deformities

Helmet therapy

Otitis Media

Infection of the middle ear, most commonly viral or bacterial

Most common bacteria are: Strep pneumonaie, non-typeable

H. influenzae, Moraxella cattharalis

Classified as Acute (AOM), chronic, or recurrent OM with

effusion

Effusion can remain after an infection for up to 3 months in 10%

of children (up to 1 month in 40%)

First line antibiotic treatment is high dose Amoxicillin

AAP guidelines published February 2013 discuss the proper

diagnosis and treatment of AOM, including when observation
is appropriate vs. introduction of antibiotics (this inadvertantly
happens to be a GREAT time to introduce OMT!!! )

The Trouble with

Anatomy
The anatomy of the ear in
childhood sets the stage for
more frequent ear infections

Eustachian tubes

Run from the middle ear, along

the petrous portion of the
temporal bone, across the
petrosphenoidal junction, past
the palatine muscles to end in
the nasopharynx

Serve to drain fluid

accumulated in the middle
ear, and to allow air
movement to regulate
pressure (think airplane)

The narrowest point in the

pathway is over the
petrosphenoidal junction, where
the tube is surrounded by a sling
of connective tissue

Myofascial and cranial strains

through this area can impede

Their heads are just

different
The development of the skull from chilhood to adulthood
also changes the location of the ear in relation to the
nasopharynx. In children, the eustachian tube is much
more horizontal

As we grow, the face elongates forward and up/down and the

ears orient higher in the skull. This results in more angle to
the eustachian tube, allowing gravity to assist with drainage
(this becomes more evident after 6yo, at which time we
notice a decline in the number of ear infections in general)

EAC

Muscle Trouble

The tensor veli palatini attaches to the lateral wall of the

eustachian tube at the nasopharynx, and opens the tube
when it contracts

It works to pump the tube to assist with drainage

Floppy musculature can result in difficulty opening the tube
and decreased drainage
In kids, hypertonicity of the muscle can also distort the tube
because it is more pliable and result in poor drainage from
positioning

The Medial Pterygoid (not usually associated with the

eustachian tube), runs right by the opening

Can have fibrous attachments to the opening of the tube

When contracted, the bulk of the muscle can obstruct the
eustachian tube (hypertonicity and increased muscle bulk
can significantly affect drainage)

Im a little stuffy

The mucosa of the middle ear

and eustacian tube is similar to
that of the nasopharynx
lymphoid tissue with secratory
glands

So when the nose gets irritated

and produces more mucous, so
does the ear
Chronic stimulation results in
increased viscosity of the
mucous produced
The longer it sits in the ear, the
more likely it is to breed nice,
healthy bacteria (not so good
for the host major ear
infection!!!)

OMT to the Rescue!!!

OMT in the presence of AOM is used to promote

drainage of the fluid and reduction in viscosity of that
fluid

Common areas to treat are cranial strains, the medial

pterygoid, cervical musculature, thoracic inlet,
OA/AA, upper thoracics (autonomic influences!!!)

This is very helpful in reducing the amount of fluid

accumulation in the middle ear, allowing for faster
resolution of infection, and reduction of recurrence

This does not replace the use of antibiotics, which are

still appropriate for some patients/situations

References

Behrman: Nelson Textbook of Pediatrics, 18th ed.

Carreiro, J. An Osteopathic Approach to Children,

1st ed.

American Academy of Pediatrics (www.aap.org)

Allan S. Lieberthal A. S., et al;The Diagnosis and

Management of Acute Otitis Media; Pediatrics;
originally published online February 25, 2013;
DOI: 10.1542/peds.2012-3488

http://www.thecraniofacialcenter.org/index.html

http://emedicine.medscape.com/article/994656-o
verview