Torticollis
- Common neck posture of a patient with torticollis, note the spasm/activation of the SCM
- Caused by involuntary unilateral contraction of the SCM and Traps other muscles are splenius, scapula muscles, scalenes and platysma
- More common in females aged 30-50 years
- Causes lateral flexion and contralateral rotation
- Anterocollis more rare, rotational more common
Types of Torticollis
- Congenital: (caused by lesions in SCM (childbirth trauma), vertebral defomities e.g Hemivertebra, klippel feil)
- Acquired: post trauma (within days or 3-12 months)/adjacent inflammatory process (Osteomyelitis,lymphadenitis, pharygitis, tonsilitis, cervical abcesses, tumour, RA, Partial dislocation of C1 on C2
- Spasmodic: Cervical Dystonia - unknown origin
- Acute: Benign - affects younger and middle aged patients , sudden onset -self resolves days/weeks
- Dermatogenic: When the skin of the neck is injured it shortens (scars/burns)
- Occular: Compensational paralysis of the muscles that control inclination and rotation of the head - oblique extraoccular muscles |
Presentation
- Patient remembers doing something strenous or new the day before |
- On observation patient has painful fixed posture of lateral flexion and contralateral rotation of the head (can have flexion, extension, right/left tilt) |
- Movement is painful and ROM is limited (lateral flexion and extension to the side of pain) |
- Sleep is disturbed |
- +ve Spurlings |
- Palpation reveals unilateral hypertonicity/spasm of the SCM, traps and LS |
- Intersectional joint restricion |
- Assess shoulder, scapular girdle |
- Check for patient's drugs - Dopamine blockers, Ketamine, ammphetamines, cocaine, compazine, haldol and thorazine |
- In patients with Down syndrome with torticollis, consider atlanto-axial instability |
- Assess for s/s of cervical adenopathy (lymph nodes), oropharynx, otoscopy, fundoscopy |
DDx
- Essential Tremour |
- Myasthenia Gravis |
- MS |
- Neuroleptic agent toxicity |
- Parkinsons |
- Peritonsillar Abscess |
- Rehabilitation and cerebral palsy |
- Retropharyngeal Abscess |
- Spinal Haematoma |
- Tardive Dyskinesia |
- Wilson disease |
Imaging
Usually unnecessary unless: |
- Trauma and "red flags" |
Red Flags
- Fever (infection/inflammatory - usualy septic otolaryngological/osteoarticulr infection) |
- Swollen Lymph nodes |
- Significant headache |
- Difficulty breathing, swallowing or speaking |
- Ataxia |
- Weakness, numbness or parasthesia in extremities |
- Change in bladder/bowel habits |
- Strabismus |
- Nystagmus |
- Increased ICP (Vomiting, Double vision, Confusion, headache, papiloedema) |
- Reccurent vomiting |
Management
- More serious causes should be ruled out |
- Ice/heat |
- Myofascial release of SCM, traps, LS and paraspinal muscles |
- Stretching - Cx tractioning whilst resting your forearms on the patient's shoulders, forearms downward pressure, then ask patient to push against forearms with their shoulders against your resistance for 5-7 seconds while inhaling, ask patient to exhale and then stretch out and increase traction, process should be repeated 3 times |
- Scapula repositioning |
- SMT if tolerable |
- Avoidance of sleeping on the stomach or drafty conditions |
- Cervical pillows recommended |
- NSAIDs and counterirritant creams, Benzodiazepines, muscle relaxants, anticholinergics, botox |
- Surgery for some types |
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