Torticollis

What is Torticollis?

Torticollis, also known as twisted neck, is a condition where the head and neck seem stuck or inclined in a particular position. This awkward position could mean the head and neck are leaning or twisted in unusual ways, either to the front, back, right or left. There are different types of torticollis named after the type of tilting like horizontal, vertical, oblique, or torsion.

Torticollis is quite common, and nearly 90% of people might experience at least one episode of torticollis during their lifetime.

Sometimes, torticollis can be harmless or congenital (present from birth), but it can also be caused by serious things like an injury to the brain.

Typically, most torticollis cases are associated with problems in the local nerve-muscle interactions, which is a condition called focal dystonia. Cervical dystonia, a type of focal dystonia, is quite common in adults and usually results in a stiff or contracted state of neck muscles like the sternocleidomastoid and/or trapezius muscles.

The way the neck appears can change depending on the specific muscles affected. It’s crucial to note that not all abnormal positions of the head and neck mean torticollis.

Talking about the neck’s muscle structure, there are layers of muscles – the superficial ones on the outside, and the deeper ones near the spine.

Key muscles involved in torticollis are the sternocleidomastoid, commonly impacted. You can see and feel it in the front part of the neck, and its job is to help turn the head to the opposite side, tilt the head to the same side, and bend the head forward.

Other neck muscles involved in torticollis include the splenius, trapezius, the muscles attached to the shoulder blade, scalenes, and platysma.

There are eight pairs of neck (cervical) nerves, named from C1 to C8, each leaving the spinal cord at the corresponding vertebrae level in the neck. These nerves can often be pressured or squeezed associated with disease changes.

What Causes Torticollis?

Torticollis is a condition where the neck is twisted and causing head tilt. It can be caused by several different factors, including some serious diseases.

Here are the main types of torticollis:

– Congenital torticollis: This is when it’s present from birth. It can happen because of an injury during birth that causes swelling in the muscle, leading to a condition where the fibers of the neck muscle become short and fibrous (hardened).
– Dermatogenic pain: This is when an injury to the skin of the neck causes it to shrink, which can then limit neck movement. This type usually happens in cases of burns or scars.
– Ocular torticollis: This refers to a condition where the muscles that control the tilt and rotation of your head lose function. This usually happens because of a problem with the eye’s oblique muscles, which control the eye’s movement.
– Rheumatological torticollis: This type is related to various diseases that affect the joints, muscles, bones, and tendons.
– Vestibular torticollis: This originates from an issue with the inner ear, specifically the labyrinth, which is responsible for balance.
– Neurogenic torticollis: This form is a result of any neurological disorder or accident, such as a stroke or trauma.
– Spasmodic torticollis (dystonia): This is the most common cause of neck stiffness and occurs due to increased muscle tension.The usual triggers are emotional stress, physical overload, or sudden movement.

Results from torticollis can stem from an issue in the neck area itself or from disorders affecting the brain.

Cervical dystonia, another name for torticollis, can be classified into two categories.
Primary (or idiopathic) cervical dystonia is when there is no injury of a particular brain region, and it tends to have a genetic basis. On the other hand, secondary cervical dystonia could be associated with trauma, drug use, or a specific disease trigger. Its cause can, therefore, be traced back to a known external factor.

Risk Factors and Frequency for Torticollis

Torticollis, a condition affecting the neck, is caused by trauma in 10 to 20% of cases; the rest of the cases are of unknown cause. Usually, post-traumatic torticollis will show up within days to a year after an injury.

This condition often presents in different movement patterns. The most common type involves some degree of neck rotation. Other types, in decreasing order of frequency, include torticollis with side tilting (laterocollis), backward bending (retrocollis), and forward bending, which is the least common (anterocollis).

• Torticollis can be caused by trauma or has no known cause.
• Post-traumatic torticollis usually starts within days to a year after the injury.
• The most common type involves neck rotation.
• Other types include torticollis with side, backward, and the least common forward bending.
• Women are twice as likely to have this condition as men.
• Torticollis of unknown cause (idiopathic) tends to start in people aged 30 to 50.
• A form of the disorder present at birth (congenital muscular torticollis) is found in less than 0.4% of newborns.

Signs and Symptoms of Torticollis

Torticollis is a health condition that causes a person’s head to tilt to one side. To help diagnose and manage this condition, doctors require detailed information on the person’s symptoms, emotional status, personal and family history, any other health conditions, changes in medication, and the age when the symptoms first began. They will also look at if the person’s torticollis is a long-term or short-term issue, if symptoms regularly come and go, and how those symptoms developed. If the person has any pain, it’s also crucial to determine where this pain is originating from. This could mean it is coming from bone, central areas, muscles, or from past radiation treatment.

On top of this, a physical examination is performed. The doctor will examine the patient’s posture, whether their head tilt is constant or not, if there are any limitations in their movement or anything that eases their symptoms, and if there is any tenderness in the bones or muscles when touched.

Diagnosing torticollis is usually straightforward if the person’s head leans to one side and their neck rotates to the other side. However, if the person arrives with their spine immobilized by emergency medical services and their head held rigid, the diagnosis might be a bit more challenging.

Physical examination will typically reveal moderate and severe cases of torticollis. If this condition is left untreated in children, it can be not only uncomfortable and unpleasant to look at, but also harmful to the development of their neck and face.

• Symptoms associated with torticollis (including vomiting, fever, infection signs, balance issues, related headaches, and vision changes)
• Emotional state
• Personal and family context, particularly if torticollis occurs during the newborn stage (details about birth, the newborn period, any known issues like chromosomal changes, body disease, organ or bone malformations, muscle fibrosis, eye misalignment)
• Whether torticollis is a short-term or long-term problem
• Associated health conditions
• If symptoms are permanent or come and go
• Recent medication changes
• Age when symptoms first began
• The patient’s posture
• If the head tilt is constant or intermittent
• Any movement restrictions and what helps relieve them
• If there is bone or muscle tenderness when touched.
• If pain is present and its source (bone, central, muscle, previous radiation)

Testing for Torticollis

If your doctor thinks you may have torticollis, a condition where your neck muscles contract causing your head to tilt, they can usually diagnose it based on your symptoms and a physical examination. In some instances, however, they may need to run additional tests to better understand or confirm what’s happening. These tests are determined on a case-by-case basis.

These may include X-ray pictures, a CT scan, ultrasound imaging, and blood tests. The blood tests can check for metabolic or genetic factors that might be contributing to your condition.

If you’re experiencing spasmodic torticollis, which involves sudden, painful neck muscle contractions, your doctor will check for stiffness and pain in your neck and shoulder muscles. They’ll also observe the flexibility and movement of your spine. In some cases, they might need to use X-ray or CT imaging to see if there’s any abnormality, like a fracture or misaligned bone in your spine.

If your torticollis is persistent, your doctor will check for eye conditions like strabismus (crossed eyes) and nystagmus (rapid uncontrolled eye movement). They’ll also look for signs of increased pressure inside your skull or any other unusual neurological signs. If you’re experiencing ongoing vomiting alongside persistent torticollis, this is a warning sign that requires an in-depth neurological examination. Sometimes, imaging tests are used to check for injuries inside the brain, and you might need to see an eye specialist if the movement of your eyes is abnormal.

If you have a fever, it could suggest an infection or inflammation is in play. It’s important to rule out infection-related issues in the ear, nose and throat area or in the bones and joints. A focus of the physical examination will be checking for swollen lymph nodes in the neck, examining your throat and mouth, and examining your ears with an instrument called an otoscope. If there’s suspicion of an abscess in the space behind your throat, a CT scan would be needed. If your neck is tender, it might point towards a bone infection or inflammation between the discs in your spine. Lab tests can provide additional information. Other imaging techniques, such as an MRI or scintigraphy (a type of imaging test that uses radioactive substances and a special camera), can also assist in the diagnosis.

Treatment Options for Torticollis

Currently, there is no specific cure for neck conditions known as cervical dystonias. However, several treatments are available to help reduce and relieve symptoms. These include medications like benzodiazepines, which help with anxiety and muscle spasms; muscle relaxants, which help to relieve muscle tension; and anticholinergics, which work against a specific chemical messenger in your nervous system known as acetylcholine.

Another treatment possibility is an injection of botulinum toxin, which is a substance that can relax the muscles. In some cases, corrective surgery might be needed. Alternative treatments to manage symptoms and improve movement include physiotherapy and osteopathy, which involve techniques to massage, manipulate, or stimulate the body’s tissues.

Physiotherapy, in particular, plays a crucial part in treating many different types and causes of muscle contractions in the neck, also known as torticollis.

What else can Torticollis be?

These are possible conditions that could present similar symptoms and therefore, need to be considered during the diagnosis:

• Essential tremor
• Myasthenia gravis
• Multiple sclerosis
• Neuroleptic agent toxicity
• Parkinson disease
• Peritonsillar abscess
• Rehabilitation and cerebral palsy
• Retropharyngeal abscess
• Spinal hematoma
• Tardive dyskinesia
• Wilson disease