Treatment of Adult Female Torticollis
For adult female torticollis, initiate multimodal therapy with NSAIDs as first-line treatment combined with heat application and gentle stretching exercises, reserving botulinum toxin injections or surgical myotomy for cases that fail conservative management after 4-6 weeks. 1
Initial Conservative Management
Pharmacological Approach:
- NSAIDs serve as the primary analgesic for pain control and inflammation reduction 2, 1
- Add muscle relaxants to reduce muscle spasm (avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain) 2, 1
- For severe pain with significant inflammation, consider a short course of oral corticosteroids 2, 1
Physical Interventions:
- Apply heat therapy to tense muscles for 15-20 minutes, 3-4 times daily to improve blood circulation 2, 3
- Implement gentle stretching exercises to gradually restore normal range of motion 2, 1
- Ensure proper head positioning during rest and sleep 2, 3
- Initiate supervised postural exercises with manual trigger point therapy 2, 1
Critical Diagnostic Considerations
Rule out secondary causes before proceeding with treatment:
- Ocular causes must be excluded, particularly eye muscle weakness presenting as compensatory head tilt, which may require prism glasses or surgical intervention for diplopia control 1
- In elderly patients, scalp tenderness with jaw claudication suggests giant cell arteritis and demands urgent evaluation with ESR, CRP, and temporal artery biopsy 1
- Progressive neurological symptoms (weakness, numbness, tingling) suggesting spinal cord compression require immediate neuroimaging 2, 3, 1
Advanced Treatment for Refractory Cases
Botulinum Toxin Therapy:
- For persistent congenital muscular torticollis (CMT) in adults, botulinum toxin injections provide successful long-lasting benefit 4
- This approach is particularly effective in adult CMT characterized by cord-like sternocleidomastoid muscle, facial asymmetry, absence of head tremor, and head tilt since infancy 4
Surgical Intervention:
- Minimal-incision myotomy under local anesthesia is appropriate for mild CMT with recognizable head tilt and palpable fibrotic band in the sternocleidomastoid muscle 5
- Surgical indication is reserved for patients with mild fibrotic band and minimal length discrepancy between muscles 5
- This technique offers complete restoration of range of motion with high patient satisfaction and no morbidity in carefully selected adult female patients 5
- For more severe cases, inferior open tenotomy of the sternal and clavicular heads of the sternocleidomastoid muscle remains the most popular and reliable procedure 6
- Incisions should be placed low in the neck along skin lines (not over the clavicle) to avoid hypertrophic scarring 6
- Two-stage bipolar surgical division with gradual stretching in a halo-vest can achieve near-full range of motion without major complications 7
Important Clinical Pitfalls
Physical therapy alone is ineffective in adult CMT because sternocleidomastoid muscle development is complete, unlike in pediatric cases where conservative treatment during the first year of life is highly successful 5, 6
Facial asymmetry and underlying skeletal changes will not reverse with treatment in long-standing adult cases, though functional improvement and pain relief can be achieved 7
Only modest results should be anticipated in adults with long-standing disease or advanced craniofacial asymmetry, making early intervention critical 6
Novel Emerging Approaches
Percutaneous myotomies combined with intramuscular stromal vascular fraction-enriched fat grafting has shown promise for simultaneous recovery of neck aesthetics and muscle function with minimal scarring and short recovery time, though this requires further long-term safety evaluation 8