What is the initial treatment for a patient presenting with torticollis?

Initial Treatment for Torticollis

The initial treatment for 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. 1

Diagnostic Approach

When evaluating a patient with torticollis, it's crucial to determine whether the condition is:

1. Ocular torticollis: Associated with strabismus or cranial nerve palsies
2. Muscular torticollis: Involving the sternocleidomastoid muscle
3. Neurogenic torticollis: Related to CNS dysfunction
4. Secondary torticollis: Due to various causes like atlantoaxial rotatory displacement, Grisel's syndrome, or Sandifer syndrome

Key Diagnostic Elements

• Duration: Separate acute from chronic forms 2
• Associated symptoms: Look for neurological symptoms, facial asymmetry, head tremor
• Physical examination: Check for cord-like sternocleidomastoid muscle, sensory tricks, and head position 3
• Imaging: For acute traumatic torticollis, standard radiographs followed by dynamic evaluation after 15 days; MRI for recurrent forms or those with neurological abnormalities 2

Treatment Algorithm

1. Ocular Torticollis

• First-line treatment: Occlusion therapy, temporary prism glasses 1
• Second-line treatment: Botulinum toxin injection to affected extraocular muscles 1
• Surgical options: Consider after 6 months of conservative treatment
  • Medial rectus recession and lateral rectus resection
  • Transposition procedures of vertical recti muscles 1

2. Muscular Torticollis

• First-line treatment: Physical therapy with or without bracing 4
• Second-line treatment: Botulinum toxin injections into the affected sternocleidomastoid muscle 3
• Surgical options: Sternocleidomastoid muscle lengthening or release if no improvement after 6-12 months of conservative therapy 4

3. Neurogenic Torticollis

• Urgent referral: To a neurologist or neurosurgeon if associated with neurological symptoms 1
• Imaging: MRI brain and cervical spine with contrast
• Treatment: Surgical decompression when indicated (hydrocephalus, Arnold-Chiari malformation, syringobulbia, syringomyelia, neoplasms) 5

4. Secondary Torticollis

• Treat underlying cause:
  • Sandifer syndrome: Treat gastroesophageal reflux
  • Atlantoaxial rotatory displacement: Cervical collar immobilization or surgical stabilization if persistent 1
  • Septic torticollis: Treat otolaryngological infection or spondylodiscitis 2

Important Considerations

• For resistant cases, botulinum toxin injections may be effective regardless of the underlying cause 1
• Surgical intervention should be considered only after 6 months of failed conservative therapy 1
• Early treatment (within the first year of life for congenital cases) leads to better outcomes 4
• Regular monitoring of head position and range of motion is essential for all patients 1

Pitfalls to Avoid

• Failing to differentiate muscular from non-muscular torticollis (missing non-muscular causes could be potentially life-threatening) 4
• Delaying treatment beyond the first year of life in congenital cases (may lead to persistent facial asymmetry) 4
• Neglecting to perform appropriate imaging in cases with neurological symptoms or recurrent torticollis 2
• Overlooking ocular causes of torticollis, which may respond well to specific treatments 1

Regular reassessment is necessary to evaluate treatment response and adjust the management plan accordingly.