Torticollis is characterized by a lateral head tilt with the chin rotated in the opposite direction. It can be caused by many conditions, most commonly as a result of congenital asymmetry in the lengths of the sternocleidomastoid (SCM) muscles. Torticollis occurs in approximately 0.3-1.9% of all live births, more frequently in males, and most commonly on the right side. While etiology is unknown, multiple theories have been proposed, including early fetal descent causing SCM compartment syndrome, muscle fibrosis secondary to traumatic birth and vascular compromise.
While congenital muscle imbalance is the most common cause of torticollis, other causes should be ruled out, including cervical spine abnormalities, Sandifer syndrome and central nervous system tumors. Infants with torticollis have a higher likelihood of developmental dysplasia of the hips and warrant ultrasound surveillance at 4-6 months of age. Early intervention prevents further complications, including abnormal head shape, asymmetric facial features, and scoliosis.
What should the initial evaluation of Torticollis entail?
- Test passive range of motion of the neck in all directions (flexion, extension, rotation to the left and right, side-bending to the left and right)
- Palpate the sternocleidomastoid muscles for a knot
- Assess both arms for active and passive range of motion, looking for any asymmetry
What are the symptoms?
- Asymmetric frontal bossing on the opposite side of the torticollis
- Asymmetric ear position
- Asymmetric eye shape/size
- Tilted mandible
- Flattened cheek on the same side of the torticollis
- Shoulder elevation on the same side of the torticollis
What role can the primary care provider play in the evaluation of Torticollis?
- Encourage the family to perform passive range of motion and massage on a daily basis
- Place the infant in the crib with the door to the room on the opposite side of torticollis, promoting them to look towards the direction of the lights/sounds
- Encourage daily tummy time to protect head shape development
When is a referral to specialists indicated?
- When passive range of motion is limited in any direction: neck flexion, extension, rotation, or side-bending
- When the child develops facial asymmetry or abnormal head shape
- If the child does not improve with physical therapy