Torticollis

Torticollis is the stiffness of the neck muscles that causes pain and keeps the head in an abnormal position.

Symptoms and Causes

Torticollis is the abnormal contraction of the neck muscles that causes stiffness that persists over time. This tension prevents normal movement and therefore usually causes the head to tilt.

Depending on how it presents, torticollis can be classified into two types:

Fixed torticollis: muscle contraction is permanent, so the head remains in an abnormal posture continuously and always in the same position.
Intermittent torticollis: episodes of abnormal muscle twisting and head tilting occur, which may last a few minutes or persist for several days.

The prognosis of torticollis is generally good and it usually resolves within a few days. However, when appropriate treatment is not received in a timely manner or when it is of neurological origin, it may become very painful, present more severe symptoms, and take longer to correct.

Symptoms

The most characteristic symptoms of torticollis are:

Limited head movement, with the head positioned abnormally:
- Laterocollis: the head tilts laterally toward one shoulder.
- Rotational torticollis: this is the most common type. The neck tilts to one side, while the head and chin remain turned toward the opposite side.
- Anterocollis: the neck is flexed forward, bringing the head closer to the chest.
- Retrocollis: the neck is extended and the head tilts backward.
Headache.
Neck pain.
Muscle stiffness, particularly of the sternocleidomastoid muscle.
Head tremor.
One shoulder higher than the other.
Muscle inflammation.
Newborns often present with a neck mass that, if left untreated, may lead to facial asymmetry or cranial deformity.

Causes

Torticollis can be divided into two types according to its main causes:

Congenital torticollis: a condition affecting infants from birth or becoming apparent shortly thereafter. Although the exact causes of the muscle contraction are unknown in most cases, it is believed to result from an inappropriate fetal position within the uterus, leading to fibrosis and shortening of the sternocleidomastoid muscle, or from the consequences of an instrument-assisted delivery.
Acquired torticollis: develops after birth, at any age, as a result of a wide variety of factors.
- Non-dystonic torticollis: Also referred to simply as torticollis, this is a temporary mechanical condition caused by a muscle contracture resulting from:
  - Infections: meningitis, otitis, mononucleosis, mumps, tonsillitis, pharyngitis, sinusitis.
  - Dermatogenic torticollis: caused by skin infections, scarring, inflammation, or burns.
  - Cervical, spinal cord, or brain tumors.
  - Injuries resulting from trauma (whiplash injury, falls) or poor posture (while working at a computer or reading).
  - Ocular torticollis: muscles shorten due to an abnormal head position resulting from visual disorders.
  - Stress.
  - Anxiety.
  - Hysterical torticollis: caused by the somatization of severe stress or psychological trauma.
- Dystonic torticollis: Also known as spasmodic torticollis, whose medical term is cervical dystonia, it is a chronic disorder of the central nervous system. The causes are unknown, although genetic factors are believed to be involved and it may occur as a consequence of the side effects of certain medications.

Risk Factors

The risk of developing torticollis increases in the following situations:

Excessive screen use, which requires the neck to remain flexed forward for prolonged periods.
Sudden movements of the neck or head.
Poor sleeping posture, for example lying face down with the head turned or using excessively high pillows.
Overexertion or carrying excessive weight.
Exposure to cold temperatures or drafts.
Accumulated stress or emotional tension.
Infections affecting the head and neck region.
Genetic predisposition.
History of head or neck trauma.
Being female and over 30 years of age.

Complications

When torticollis does not receive appropriate treatment, the following complications may arise:

In adults with acquired torticollis:
- Chronic pain.
- Dizziness or a sensation of instability.
- Vertigo.
- Compression of nerve roots, presenting as tingling sensations or loss of strength in the arms.
In children with congenital torticollis:
- Plagiocephaly: flattening of the skull due to keeping the head resting on the same area continuously.
- Facial asymmetry.
- Balance problems.
- Delayed psychomotor development: difficulty controlling the head, rolling over, sitting independently, or crawling.
- Scoliosis: abnormal curvature of the spine.

Which specialist treats torticollis?

Most patients receive treatment for torticollis within the specialties of Family and community medicine or Physical medicine and Rehabilitation. However, more severe cases are managed by specialists in Traumatology and Orthopedic surgery, Neurology, or Neurosurgery.

Diagnosis

The diagnosis of torticollis is predominantly clinical, with particular importance placed on:

Medical history: information is gathered regarding the patient’s family and personal history, as well as lifestyle. Symptoms and potential triggering events are also assessed.
Physical examination: the neck is observed and palpated to assess head position, muscle condition, and the presence of abnormal masses or tumors. Range of motion is evaluated to determine movement limitations and whether pain occurs during mobilization.

In more complex cases, imaging studies (X-ray, magnetic resonance imaging, or computed tomography) may be necessary to identify the affected muscles and determine whether other bone or tumor-related conditions are causing the head tilt.

Treatment

Treatment of torticollis varies according to the underlying cause and the severity of symptoms. The most effective approaches include:

Congenital torticollis
- Physical therapy to stretch the shortened muscle:
  - Therapeutic massage to relax the affected area and promote flexibility.
  - Stretching exercises to improve mobility.
  - Auditory or visual stimuli to encourage conscious movement.
Non-dystonic torticollis: Treatment focuses on the underlying cause and typically includes antibiotics (in cases of infection), analgesics, muscle relaxants (if severe contracture is present), and physical therapy, including exercises to increase range of motion. The temporary use of a cervical collar may be recommended when the condition results from trauma.

Dystonic torticollis: Management is more complex and may include:
- Medication to reduce muscle contractions, such as muscle relaxants or anti-inflammatory drugs.
- Botulinum toxin injections to weaken the affected muscle and reduce spasms.
- Physical therapy to improve muscle flexibility and mobility.
- Surgery: in severe cases that do not respond to more conservative treatments, surgical intervention may be required:
  - Selective denervation: the nerves supplying the affected muscles are severed to eliminate the abnormal signals causing the spasms.
  - Deep brain stimulation (DBS): electrodes are implanted in the brain to deliver electrical impulses that block the signals responsible for uncontrolled movement.