Torticollis

Last updated: March 17, 2021

Summary

Torticollis is a clinical finding in which the neck twists to one side, with an associated asymmetric head or chin position. It is characterized by abnormal tone or length of the cervical muscles, which may be congenital or acquired, and can be the result of a variety of mechanisms (e.g., trauma, muscle tone disorders, congenital muscle tightness, extrinsic masses, ocular, etc.). Torticollis is predominantly a clinical diagnosis. Imaging may be required to determine the underlying etiology. Initial treatment consists of physical therapy (exercises for muscle lengthening and balance) and medication for dystonia (anticholinergics, benzodiazepines, baclofen). Surgical release is used for severe cases involving muscle shortening.

Epidemiology

Congenital (also referred to as infantile torticollis)
- Age: 2–4 weeks
- Sex: ♂ > ♀ (3:2) ^[1]
Acquired
- Wry neck/stiff neck : the most common type of torticollis in adults
- Idiopathic cervical dystonia
  - Age of onset: ∼ 50 years ^[2]
  - Sex: ♀ > ♂ (2:1)

Epidemiological data refers to the US, unless otherwise specified.

Types of torticollis

Overview of torticollis forms ^[3]
Type	Etiology	Clinical features	Management
Congenital torticollis	Any postural deformity of the neck that develops prenatally Birth trauma or intrauterine malpositioning that leads to congenital muscular damage (e.g., muscular tightness, thickening, or shortening) to the sternocleidomastoid Pterygium colli (webbed neck) Hypertrophy or absence of cervical musculature Spina bifida Hemivertebrae Arnold-Chiari syndrome	See congenital torticollis Head tilt Limited passive range of motion Palpable thickening of the sternocleidomastoid muscle	Physiotherapy: passive positioning Surgery at 12 months of age if conservative management is insufficient
Acute torticollis (wry neck)	Trauma Poor posture Local exposure to cold	Spontaneous onset (usually, overnight and without provocation) One or more painful neck muscles that limit the range of motion of the neck Self-limiting (resolves spontaneously in 1–4 weeks)	Mild cases with history of only poor sleeping posture or strain can be treated with: Physiotherapy Local warmth Stretching exercises Cervical collar Analgesics: NSAIDs, acetaminophen, opiates, or anticholinergics If there is inadequate response to physiotherapy and analgesics or in the case of persistent pain and stiffness: Botulinum toxin injection Benzodiazepine (e.g., clonazepam) In cases of acute drug induced dystonia: Baclofen Surgical release may be considered for refractory cases.
Idiopathic cervical dystonia (spasmodic torticollis)	A definitive etiology is not yet clear.	See “Spasmodic torticollis“ in “Dystonia.”	See “Treatment” in “Dystonia.”
Other forms of acquired torticollis	Dystonic torticollis Trauma Drug-induced dystonic reaction: addictive drugs such as ketamine, amphetamines, and cocaine; neuroleptic drugs such as prochlorperazine, haloperidol, and chlorpromazine Nondystonic torticollis Cervical muscular spasm Infection Spondylosis Tumor Esophageal reflux Neurological causes: Cerebral palsy Posterior fossa tumor	Similar to other forms of torticollis Additionally, features of the underlying pathology (e.g., fever in cases with infection or neurological pain in cases with spondylosis with nerve compression)	Treatment of underlying causes: Antibiotics for underlying infection PPIs for reflux induced fibrosis Withdrawal of the offending agent in the case of drug-induced reactions IV diazepam or diphenhydramine is useful in drug-induced reactions
Other forms of acquired torticollis	Ocular torticollis Congenital nystagmus Superior oblique paresis (fourth cranial nerve palsy; see cranial nerve disorders) Dissociated vertical deviation Brown syndrome: a rare form of strabismus that presents with limited elevation of the affected eye Refractive errors	Abnormal head position Bielschowsky test (head tilt test): method used to isolate the malfunctioning extraocular muscle, particularly the superior oblique muscle and trochlear nerve (cranial nerve IV)	Extraocular muscle surgery (see treatment of ocular motility disorders) Physiotherapy

Torticollis

References

Amaral DM, Cadilha RPBS, Rocha JAGM, Silva AIG, Parada F. Congenital muscular torticollis: where are we today? A retrospective analysis at a tertiary hospital. Porto Biomedical Journal. 2019; 4 (3): p.e36.doi: 10.1097/j.pbj.0000000000000036 . | Open in Read by QxMD
LeDoux MS. Dystonia: phenomenology.. Parkinsonism Relat Disord. 2012; 18 Suppl 1: p.S162-4.doi: 10.1016/S1353-8020(11)70050-5 . | Open in Read by QxMD
Karmel-Ross K. Torticollis: Differential Diagnosis, Assessment and Treatment, Surgical Management and Bracing . The Haworth Press, Inc ; 1997

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