Torticollis, also known as “wryneck,” is a condition in which the baby’s head is tilted. The chin points to one shoulder, while the head tilts toward the opposite shoulder. Treatment is necessary to prevent the baby’s face and skull from growing unevenly and to prevent limited motion of the head and neck. [1] The reported incidence of congenital torticollis is 0.3-2.0%. [2]

“Congenital” means a condition that is present at birth. Congenital torticollis occurs at or shortly after birth. The cause is suspected to be birth trauma or intrauterine malposition causing damage to the sternocleidomastoid muscle  in the neck.[3] The injured muscle may bleed and swell. And scar tissue may replace some of the muscle, making it shorter. Torticollis may also occur later in life, called Acquired torticollis.

On examination these children are found to have a head tilt to one side. The chin points to one shoulder, and the head tilts toward the opposite shoulder. If, the head tilts to the right and the chin points left, meaning the muscle on the right side is affected. The patient may also have a palpable lump in the affected side sternocleidomastoid muscle if the case presents early, this mass may disappear by 8-10months of life, leaving a fibrotic muscle behind. The patient may have noticeable restriction of neck movements in comparison to other children. Children who present later may also have Facial Hemi-hypertrophy and Plagiocephaly (asymmetrical flattening of the skull on one side).

After history taking and thorough clinical examination by a pediatric surgeon, diagnosis of congenital torticollis can be easily made. An X-ray neck must be done to rule out other bony causes of torticollis.

Initially, conservative management may be tried, physiotherapy and certain postural exercises may be tried during feeding and sleeping to help you stretch your baby’s neck so that he or she rotates the chin toward the shoulder of the affected side. If the baby does not improve after a few months of  stretching, the doctor may suggest surgery. Approximately 10% of children with congenital muscular torticollis require surgery. The surgery should be done at the right time to avoid progressive Cranio-Facial asymmetry, which can be very disfiguring.

The operation is typically scheduled once the child reaches preschool years. The surgery entails release of both the heads of the shortened and fibrotic SCM muscle to allow movement and allow head without tilt. Usually traditional opensurgery ends up in a lifelong noticeable scar in the neck. Scarless surgery is in great demand today. Stealth surgery refers to endoscopic subcutaneous procedures performed without leaving any obvious evidence that ansurgery has occurred. It involves release of both the heads of the fibrotic SCM in children through a hidden incisions in the axilla.[4]

Stealth and open release techniques have equal functional outcomes and better cosmetic outcome. [5]

After surgery the child will be required to wear a soft neck collar. There will be an intense physiotherapy program for 3–4 months as well as strengthening exercises for the neck muscle [6].

Advantages of Subcutaneous Endoscopic Release of Torticollis

1) Small hidden incisions 2) Prevents scarring in the head and neck region which are prone for keloid formation 3) Avoiding injury to important structures by endoscopic assisted magnified view and 4) No disfigurement 5) Shorter hospital stay 6) Better wound healing.

 

 

 

 

References-

1. Tomczak, K (2013). “Torticollis”. Journal of Child Neurology.
2. Cheng, JC; Wong, MW; Tang, SP; Chen, TM; Shum, SL; Wong, EM (2001). The Journal of bone and joint surgery. American volume. 83–A(5): 679–87. “Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases”.
3. Cooperman, Daniel R. (1997). Karmel-Ross, Karen, ed. Physical & Occupational Therapy in Pediatrics. 17(2): 1–11“The Differential Diagnosis of Torticollis in Children”.
4. Pimpalwar A¹,Johny C. PediatrSurg Int. 2011 May;27(5):541-3. Transaxillarysubcutaneouscopic sternocleidomastoid tumor division for treatment of persistent torticollis in children: our technique.
5. Tokar B¹,Karacay S², Arda S¹, Alici U¹.Eur J Pediatr Surg. 2015 Apr;25(2):165-70. Para-axillary subcutaneous endoscopic approach in torticollis: tips and tricks in the surgical technique.
6. Seung, Seo (2015). “Change of facial asymmetry in patients”. Medscape.