Treatment of Torticollis in Children
Physical therapy with stretching exercises is the first-line treatment for congenital muscular torticollis in children, with surgical intervention reserved for cases that fail to respond to conservative management after 6-12 months.
Diagnosis and Classification
Before initiating treatment, it's essential to differentiate between different types of torticollis:
- Congenital Muscular Torticollis (CMT): Most common form in children, involving tightness or contracture of the sternocleidomastoid muscle
- Benign Paroxysmal Torticollis (BPT): Recurrent episodes of abnormal head postures, usually before 3 months of age 1
- Non-muscular causes: May include neurological, ocular, orthopedic, or inflammatory conditions
Treatment Algorithm
First-Line Treatment: Conservative Management
Physical Therapy
- Manual stretching exercises of the sternocleidomastoid muscle
- Should be initiated as early as possible, ideally within the first year of life
- Typically involves 3-4 months of consistent therapy
- Parents should be taught home stretching exercises to perform multiple times daily
Positioning Techniques
- Encourage active rotation toward the affected side
- Position toys and stimuli to promote head turning to the affected side
- Avoid prolonged time in car seats or carriers that restrict movement
Address Associated Conditions
- For positional plagiocephaly: repositioning strategies and potentially helmet therapy
- For hip dysplasia: appropriate orthopedic management
Second-Line Treatment: Intermediate Interventions
If no significant improvement after 3-6 months of consistent physical therapy:
Botulinum Toxin Injection
- Effective for recalcitrant idiopathic muscular torticollis 2
- Injected into the affected sternocleidomastoid muscle
- Serves as an adjunct to physical therapy
- Can potentially avoid the need for surgical release 2, 3
- Should be followed by continued physical therapy
Third-Line Treatment: Surgical Intervention
Surgery is indicated when:
- Torticollis persists despite 6-12 months of conservative treatment
- Child is approaching school age with persistent deformity
- Significant facial or cranial asymmetry is developing
Surgical Options:
- Inferior open tenotomy: Most reliable procedure involving release of sternal and clavicular heads of sternocleidomastoid 4
- Superior open tenotomy: Mastoid release
- Muscle lengthening procedures
- Sternocleidomastoid excision: In severe cases
Surgical Principles:
- Identify and release all restricting bands
- Achieve full range of motion during procedure
- Resume physical therapy within 2 weeks post-surgery to prevent recurrent contracture 4
- Place incisions low in the neck along skin lines to minimize scarring
Special Considerations
Age-Related Factors
- Best outcomes achieved when treatment begins before 1 year of age
- Reversal of craniofacial asymmetry is more successful at younger ages 4
- Children older than 1 year have increased rates of requiring surgical intervention 5
Warning Signs for Non-Muscular Torticollis
Always rule out serious causes before proceeding with treatment:
- Neurological symptoms (headaches, vomiting, weakness)
- Fever or signs of infection
- Rapid onset or progression
- Abnormal neurological examination
- Absence of palpable sternocleidomastoid tightness
Follow-Up and Monitoring
- Regular assessment of neck range of motion
- Monitoring for development of plagiocephaly or facial asymmetry
- Assessment of developmental milestones
- For post-surgical patients, close monitoring for recurrent contracture
Prognosis
- Excellent outcomes (>90% success) when treatment begins in the first year of life
- Poorer outcomes for facial and cranial asymmetry if treatment is delayed
- Surgery may improve range of motion but not necessarily resolve established facial asymmetry or cranial molding 5
Remember that early recognition and intervention are key to successful management of torticollis in children, with physical therapy being the cornerstone of treatment.