What is the treatment for torticollis (wry neck) in pediatric (peds) patients?

Treatment of Torticollis in Pediatric Patients

Physical therapy is the first-line treatment for congenital muscular torticollis in pediatric patients, with early intervention (before 1 year of age) showing the best outcomes for complete resolution.

Diagnosis and Classification

Torticollis (wry neck) in pediatric patients presents as a tilted head position with rotation and lateral flexion of the neck. It can be classified into:

1. Congenital Muscular Torticollis (CMT) - Most common form:

   • Postural torticollis: Only postural deformity in neck
   • Muscular torticollis: Neck deformity with muscle tightness and restricted range of motion
   • Sternomastoid tumor/pseudotumor: Fibrotic sternocleidomastoid muscle mass with range of motion limitations 1

2. Non-muscular causes - Require different management approaches:

   • Benign paroxysmal torticollis (BPT): Recurrent episodes of abnormal, painless head postures, usually before 3 months of age 2
   • Neurological causes
   • Ocular disorders
   • Inflammatory conditions
   • Skeletal abnormalities

Treatment Algorithm

First-Line Treatment: Physical Therapy

1. Early intervention is critical:

   • Treatment before 1 year of age has significantly better outcomes 3
   • Complete resolution is achievable in most cases when treated early 4

2. Physical therapy approaches:

   • Passive stretching of the sternocleidomastoid muscle
   • Active range of motion exercises
   • Positioning techniques
   • Parent education for proper carrying and positioning

3. Treatment setting:

   • Less severe cases: Home exercise program taught to parents
   • More severe cases (>30° limitation): Outpatient physical therapy 4
   • Average treatment duration: 2-3 months (81 days) for complete resolution 4

Second-Line Treatments

For cases resistant to physical therapy:

1. Botulinum toxin injections:

   • Effective intermediate treatment for resistant cases 1
   • Can provide long-lasting benefit even in persistent cases 5

2. Orthotic devices/bracing:

   • May be used in conjunction with physical therapy for more resistant cases 1

Surgical Management

Reserved for cases that fail conservative management:

1. Surgical indications:

   • Persistent torticollis after 1 year of age despite conservative treatment
   • Limitation of motion >30 degrees
   • Established facial asymmetry 3

2. Surgical procedure:

   • Sternocleidomastoid muscle lengthening
   • Note: Surgery may improve range of motion but not necessarily correct established plagiocephaly or facial asymmetry 1

Special Considerations

1. Timing of intervention:

   • Critical factor for successful outcomes
   • After age 1, non-operative therapy is rarely successful 3
   • Established facial asymmetry and limitation >30° at treatment initiation predict poorer outcomes

2. Differential diagnosis:

   • Rule out non-muscular causes which could be potentially life-threatening
   • Consider cervical spine radiographs to rule out skeletal abnormalities 1
   • MRI of brain and neck is generally not cost-effective or necessary for typical congenital muscular torticollis 1

3. Warning signs requiring specialist referral:

   • Neurological symptoms
   • Rapid progression
   • Associated developmental delays
   • Ocular abnormalities

Prognosis

• Complete resolution in approximately 90-95% of cases treated before 1 year of age
• Cosmetic deformity persists in approximately 31% of patients long-term 3
• Mild, asymptomatic compensatory scoliosis may develop in some patients with persistent head tilt 3

Early diagnosis and prompt initiation of physical therapy are the keys to successful management of pediatric torticollis, with the vast majority of cases resolving completely with conservative treatment when addressed before 1 year of age.