From the Guidelines
Torticollis, a condition characterized by involuntary contraction of the neck muscles, should be managed with a comprehensive approach that includes monitoring, prism glasses, and surgical intervention, as necessary, to improve vertical and torsional deviation, head posture, and the area of single binocular vision, as recommended by the Adult Strabismus Preferred Practice Pattern 1.
Diagnosis and Evaluation
The diagnosis of torticollis involves a sensorimotor evaluation with special attention to measure torsion and determine the position of gaze with the greatest deviation, using tests such as the Parks Bielschowsky three-step test 1. A complete ophthalmic examination, including a fundus examination and visual field testing, is also essential to check for other neuro-ophthalmic signs and symptoms 1.
Treatment Options
For mild cases, treatment may include monitoring and observation, while larger and incomitant deviations often require surgical intervention 1. Prism glasses may be used to manage small vertical deviations, but lateral incomitance may preclude successful implementation 1. Torsional surgery may be necessary if torsion is a barrier to fusion, typically in bilateral cases or severe unilateral cases due to trauma or cases associated with neurosurgery 1.
Key Considerations
The goal of treatment is to improve the vertical and torsional deviation, head posture, and the area of single binocular vision, with a variety of surgical choices available, including botulinum toxin injections, prism, or strabismus surgery 1. The primary diagnostician should refer the patient for evaluation by indicated neurology or otolaryngology specialists, and initial treatment with prism may be helpful to manage diplopia while waiting for possible recovery 1.
Important Factors
It is essential to assess whether torsion is a barrier to fusion and to quantify the magnitude and direction of torsional diplopia to enhance surgical planning 1. A neurological evaluation and neuroimaging may be necessary in cases with additional central nervous system signs or symptoms, or if symptomatic diplopia with poor fusional amplitudes is present 1.
From the Research
Definition and Classification of Torticollis
- Torticollis refers to a twisting of the head and neck caused by a shortened sternocleidomastoid muscle, tipping the head toward the shortened muscle, while rotating the chin in the opposite direction 2.
- It can be classified as either nonparoxysmal (nondynamic) or paroxysmal (dynamic) based on its dynamic qualities and pathogenesis 2.
Causes of Torticollis
- Causes of nonparoxysmal torticollis include congenital muscular, osseous, central nervous system/peripheral nervous system, ocular, and nonmuscular, soft tissue 2.
- Causes of paroxysmal torticollis include benign paroxysmal, spasmodic (cervical dystonia), Sandifer syndrome, drugs, increased intracranial pressure, and conversion disorder 2.
- Cyclobenzaprine, a muscle-relaxing 5-HT(2) receptor antagonist, can rarely cause torticollis as a result of toxicity 3.
Treatment and Management of Torticollis
- Available evidence recommends a combination of physical therapy (PT), occupational therapy (OT), botulinum toxin injection (BTI), and in the most severe cases, surgical release for recalcitrant torticollis 4.
- Conservative treatment modalities, such as PT and stretching exercises, can lead to the resolution or improvement of symptoms in patients with congenital muscular torticollis 4, 5.
- The American Physical Therapy Association (APTA) Academy of Pediatric Physical Therapy has developed an evidence-based clinical practice guideline for the physical therapy management of congenital muscular torticollis, which includes recommendations for education, referral, screening, examination, and intervention 5.