What are the management options for torticollis?

Management of Torticollis

The management of torticollis should be directed at the underlying cause, with nonsurgical approaches as first-line treatment including physical therapy, occlusion therapy, prisms, or botulinum toxin injections, while surgical intervention is reserved for persistent cases after 6 months of conservative management. 1

Diagnostic Classification

Before initiating treatment, it's essential to identify the specific type of torticollis:

1. Congenital Muscular Torticollis

   • Most common in infants
   • Characterized by contracture of the sternocleidomastoid muscle
   • Often associated with facial asymmetry and plagiocephaly 2

2. Ocular Torticollis

   • Associated with strabismus or cranial nerve palsies
   • Compensatory head posture to maintain binocular vision
   • May present with diplopia 1

3. Neurogenic Torticollis

   • May indicate brainstem or cervical cord compression
   • Can be associated with hydrocephalus, Arnold-Chiari malformation, or neoplasms 3
   • Requires neuroimaging for diagnosis

4. Acquired/Secondary Torticollis

   • Causes include:
     • Atlantoaxial rotatory displacement (trauma-related)
     • Grisel's syndrome (post-inflammatory)
     • Sandifer syndrome (gastroesophageal reflux)
     • Benign paroxysmal torticollis of infancy 1, 4
     • Cervical spine pathology

Management Algorithm

1. Congenital Muscular Torticollis

• First-line treatment:

  • Manual cervical stretching exercises
  • Physical therapy (most effective if started before 1 year of age) 2
  • Bracing in selected cases

• For resistant cases:

  • Botulinum toxin injections into the affected sternocleidomastoid muscle 5

• Surgical intervention:

  • Consider if no improvement after 6-12 months of conservative therapy
  • Sternocleidomastoid muscle lengthening or release
  • Note: Surgery may improve range of motion but not necessarily facial asymmetry if performed after age 1 2

2. Ocular Torticollis (Associated with Cranial Nerve Palsies)

• Monitoring/observation:

  • If symptoms are mild or patient declines treatment 1

• Nonsurgical options:

  • Occlusion therapy (patch, Bangerter filter, or satin tape on glasses)
  • Temporary prism glasses for small deviations
  • Botulinum toxin injection to affected extraocular muscles 1

• Surgical management:

  • Consider if deviation persists after 6 months
  • Options based on residual muscle function:
    • For small deviations with residual function: medial rectus recession and lateral rectus resection
    • For larger deviations without abducting force: transposition procedures of vertical recti muscles 1

3. Neurogenic Torticollis

• Urgent referral:

  • To neurologist or neurosurgeon if associated with neurological symptoms
  • Neuroimaging (MRI brain and cervical spine with contrast) 6

• Treatment:

  • Directed at underlying cause
  • May require surgical decompression of brainstem or cervical cord 3
  • For spasmodic torticollis: neuroablative procedures, selective muscle excisions, or radical cervical muscle excisions in medically refractory cases 3

4. Secondary Torticollis

• Sandifer syndrome:

  • Treatment of underlying gastroesophageal reflux 4

• Benign paroxysmal torticollis:

  • Usually self-limiting
  • Symptomatic management if associated with irritability or vomiting 1

• Atlantoaxial rotatory displacement:

  • Cervical collar immobilization
  • Surgical stabilization if persistent or recurrent 4

• Infectious causes:

  • Appropriate antimicrobial therapy
  • Surgical drainage for retropharyngeal abscess if present 4

Special Considerations

• Adult patients with persistent congenital muscular torticollis:

  • Botulinum toxin injections have shown long-lasting benefit 5
  • Can be differentiated from cervical dystonia by facial asymmetry, cord-like sternocleidomastoid, absence of head tremor, and lifelong head tilt

• Torticollis with vertebral involvement:

  • Surgical consultation should be obtained periodically during medical treatment
  • Surgical intervention indicated for spinal instability, nerve compression, or significant sequestered paraspinal abscess 1

• Red flags requiring urgent evaluation:

  • Acute onset with neurological symptoms
  • Associated with headache, vomiting, or visual disturbances
  • Progressive worsening despite treatment
  • Fever or signs of infection 7

Follow-up and Monitoring

• Regular assessment of head position and range of motion
• For ocular torticollis: periodic ophthalmological evaluation
• For neurogenic causes: neurological monitoring
• Imaging surveillance for cases with structural abnormalities

By systematically addressing the underlying cause and following this management algorithm, most cases of torticollis can be effectively treated with significant improvement in head position, function, and quality of life.