What is the initial evaluation and treatment for torticollis in an 18-month-old child?

Initial Evaluation and Treatment for Torticollis in an 18-Month-Old Child

The initial evaluation for torticollis in an 18-month-old child should include a thorough assessment to determine the underlying cause, with first-line treatment consisting of physical therapy with passive and active stretching exercises, as these are highly effective when initiated before 18 months of age.

Initial Evaluation

Clinical Assessment

• Head and neck examination:
  • Assess head position, range of motion, and presence of a palpable mass or tightness in the sternocleidomastoid muscle
  • Look for facial asymmetry and plagiocephaly (flattening of the skull)
  • Evaluate for compensatory head posture

Differential Diagnosis

1. Congenital muscular torticollis (CMT):

   • Most common cause in infants and young children
   • Characterized by shortening/fibrosis of the sternocleidomastoid muscle
   • May present with a palpable mass in the sternocleidomastoid muscle

2. Ocular torticollis:

   • Associated with strabismus or cranial nerve palsies
   • Child adopts head position to maintain binocular vision 1

3. Acquired/secondary torticollis:

   • Atlantoaxial rotatory displacement
   • Grisel's syndrome (following upper respiratory infection)
   • Sandifer syndrome (associated with gastroesophageal reflux)
   • Benign paroxysmal torticollis 1

Diagnostic Studies

• Ultrasound of the neck:

  • First-line imaging to evaluate sternocleidomastoid muscle for fibrosis or post-traumatic changes 2
  • Can reveal characteristic lesions in CMT

• Cervical spine radiographs:

  • To rule out bony abnormalities or atlantoaxial rotatory displacement 3

• Additional imaging:

  • MRI of brain and cervical spine if neurological symptoms are present 1
  • Not routinely needed for typical congenital muscular torticollis 3

Treatment Approach

First-Line Treatment

• Physical therapy:
  • Passive and active stretching exercises (PSE and ASE) of the sternocleidomastoid muscle
  • Should be initiated promptly as success rates are higher in younger children 4
  • For children under 18 months, physical therapy has excellent outcomes with low surgical rates 4

Treatment Protocol

1. Initial physical therapy regimen:

   • Stretching exercises performed multiple times daily
   • Parents should be trained to perform exercises at home
   • Regular follow-up with physical therapist to monitor progress

2. Positioning techniques:

   • Encourage active rotation of the head toward the affected side
   • Environmental modifications to promote turning toward the affected side

3. Monitoring response:

   • Regular assessment of head position and range of motion
   • Evaluate for improvement in facial asymmetry and plagiocephaly

Second-Line Treatments

• Botulinum toxin injections:

  • Consider if no improvement after 3-6 months of physical therapy
  • Injected into the affected sternocleidomastoid muscle 1, 5

• Cervical orthosis/bracing:

  • May be used as an adjunct to physical therapy in resistant cases 3

Surgical Management

• Indications for surgical referral:

  • Persistent torticollis despite 6-12 months of conservative therapy
  • Significant restriction in range of motion (>15° limitation) 2
  • Progressive facial asymmetry

• Surgical options:

  • Sternocleidomastoid muscle lengthening or release
  • Note: Surgery may improve range of motion but not necessarily facial asymmetry if performed after age 1 1, 3

Important Considerations

Prognosis

• Excellent prognosis when treatment is initiated before 18 months of age
• In children under 3 months, conservative treatment success approaches 100% 4
• Success rates decline with increasing age at treatment initiation:
  • 3-6 months: 75% success with conservative treatment
  • 6-18 months: 30% success with conservative treatment 4

Red Flags Requiring Urgent Referral

• Acute onset torticollis
• Associated neurological symptoms
• Torticollis with fever or signs of infection
• Failure to improve with appropriate therapy

Follow-up

• Regular assessment of head position, range of motion, and facial symmetry
• Adjustment of therapy based on clinical response
• Consider referral to pediatric orthopedic surgeon or neurologist if not improving with therapy

By following this structured approach to evaluation and treatment, most cases of torticollis in 18-month-old children can be effectively managed, with the best outcomes achieved through early intervention with physical therapy.