What is the management of torticollis?

Management of Torticollis

Initiate multimodal analgesia with NSAIDs as first-line therapy combined with heat application and gentle stretching exercises for acute torticollis. 1

Acute Torticollis Management

Pharmacological Approach

• NSAIDs serve as the primary analgesic for pain control and inflammation reduction in acute torticollis 1
• Add muscle relaxants to the NSAID regimen to reduce muscle spasm 1, 2
• For severe pain with significant inflammation, consider a short course of oral corticosteroids to rapidly reduce inflammation 1, 2
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain 1, 2

Non-Pharmacological Interventions

• Apply heat therapy directly to tense muscles to improve blood circulation and relax muscle tension 1, 2
• Implement gentle stretching exercises to restore normal range of motion 1, 2
• Ensure proper head positioning during rest and sleep to prevent worsening of symptoms 1, 2
• Initiate supervised postural exercises and manual trigger point therapy for muscle tension reduction 1, 2

Red Flags Requiring Urgent Evaluation

• Progressive neurological symptoms suggesting spinal cord compression require immediate imaging 1, 2
• In elderly patients, scalp tenderness with jaw claudication suggests giant cell arteritis and demands urgent evaluation 1

Pediatric Torticollis Management

Initial Assessment

• Rule out ocular causes such as eye muscle weakness that may present as torticollis in pediatric patients 1, 2
• Consider acetaminophen or ibuprofen for additional pain relief during the first 24-48 hours 2
• Consider imaging studies only if no improvement occurs with initial management or if neurological symptoms develop 1, 2

Congenital Muscular Torticollis

• Observation and physical therapy, with or without bracing, is usually effective in most cases, especially if instituted within the first year of life 3
• Botox has been shown to be an effective intermediate method of treatment for more resistant cases of congenital muscular torticollis 3
• In those presenting after the age of 1 year, there is an increased rate of sternocleidomastoid muscle lengthening 3
• Magnetic resonance imaging of the brain and neck is no longer considered cost-effective or necessary in congenital muscular torticollis 3

Important Caveat

It is critical to differentiate muscular from nonmuscular torticollis - congenital muscular torticollis is benign, but missing a case of nonmuscular torticollis could be potentially life threatening 3

Ocular-Related Torticollis

• Treatment targets include improved binocular vision, diplopia control, and reduced tilt of subjective visual vertical 1
• For small vertical deviations, manage with prism glasses, although lateral incomitance of the vertical deviation often precludes successful implementation 4, 1
• For larger and incomitant deviations, surgical intervention is most often required 4, 1
• Monitor/observe if symptoms are mild, occasional, and not bothering the patient or if the patient is opposed to treatment 4

Surgical Options for Ocular Torticollis

The goal of surgery is to improve vertical and torsional deviation, improve head posture, and improve the area of single binocular vision. Common procedures include (in combination or alone): 4

• Inferior oblique weakening by recession or myectomy (ipsilateral) 4
• Inferior rectus weakening (contralateral) 4
• Superior oblique strengthening (ipsilateral), such as tuck for lax tendons in presumed congenital cases, advancement for vertical and torsional deviations, or Harada-Ito procedure advancing only anterior superior oblique fibers 4
• Superior rectus weakening (ipsilateral) 4
• Target angle should be a small undercorrection because overcorrection, particularly in downgaze, is poorly tolerated 4

Surgical Management for Neglected Adult Cases

• In neglected adult cases of congenital torticollis, bipolar release of the sternocleidomastoid muscle followed by postsurgical physical therapy can be effective 5
• Immobilization with a brace during the first 2 weeks followed by manual stretching after brace removal achieves good functional and cosmetic results 5