File Name: congenital muscular torticollis current concepts and review of treatment .zip
Adult presentation of neglected congenital muscular torticollis CMT is rare.
Torticollis, also known as a twisted neck, is the contraction or contracture of the muscles of the neck that causes the head to tilt to one side. It is accompanied by rotation of the chin to the opposite side with flexion. Usually, torticollis is not a diagnosis but rather a manifestation of a variety of underlying conditions. It can be congenital or due to acquired causes. It can occur at any age, depending on the etiology.
The congenital form of torticollis usually presents within a few weeks after birth. Most of the time, it presents as an isolated condition. The diagnostic basis is on the clinical examination findings, and the mainstay of treatment is physical therapy.
Surgical management is an option only when medical and physical management does not show the desired results or for cosmetic reasons. Objectives: Identify the etiology of torticollis and the medical conditions and emergencies associated with this manifestation.
Review the evaluation of torticollis. Summarize the treatment and management options available for torticollis. Outline interprofessional team strategies for improving care coordination and communication to advance torticollis and improve outcomes.
The clinical term "torticollis" comes from two Latin words: tortum collum, which means twisted neck. It can result from congenital or acquired causes. Congenital torticollis is defined as a contracture or fibrosis of the Sternocleidomastoid muscle, on one side, leading to a homolateral inclination and contralateral rotation of the face and chin.
This condition requires differentiation from other forms of congenital or acquired torticollis. Congenital torticollis is the primary condition of the muscle, which is detected at birth or in the first weeks of life. The acquired torticollis are, for example, congenital skeletal anomalies, traumatic conditions, infections, inflammation of adjacent structures, tumoral conditions, ocular, and neurological dystonias. However, there is no proof for any of them. The most cited are ischemia, trauma during childbirth, and intrauterine malposition pelvic position.
The most common cause is possibly due to the result of an intrauterine deformation. The other causes of congenital torticollis are positional deformation, vertebral anomalies, unilateral atlantooccipital fusion, Klippel-Feil syndrome, unilateral absence of sternocleidomastoid, pterygium colli. The most common form of torticollis in pediatrics is Congenital muscular torticollis.
It is associated with abnormalities of the sternocleidomastoid muscle. The muscles of the neck form a complex system. Schematically, two levels are distinguished: superficial long neck muscles and deep paravertebral muscle. The sternocleidomastoid is the most targeted muscle; it is in the anterior region of the neck, where it forms a visible and palpable mass. Its insertions on the sternum sternum furcula and clavicle two-thirds medial occipital region two-thirds side of the neckline and mastoid apophysis, their fibers having an obliquely upward and outward direction.
Its action: performs contralateral rotation, ipsilateral inclination, and flexion of the head. This motor activity results in the tilting of the head and neck toward the side of the affected muscle and rotation to the opposite side. The condition typically gets diagnosed during the neonatal period or infancy. There is a preponderance to male sex and first pregnancy. It is usually identified in neonates by age 2 to 3 weeks and can persist until the age of 1 year.
It is typically unilateral, but rarely can be bilateral. In congenital muscular torticollis, the palpable mass in the sternocleidomastoid muscle is mostly made up of fibrous tissue. This mass usually disappears during infancy and is replaced by a fibrous band. The muscle biopsies and MRI studies of the mass revealed that there could be a component of muscle injury, possibly due to compression and stretching of the muscle.
The venous neck compression during childbirth may also have contributed to the decreased blood supply and subsequent compartmental syndrome. Histological studies of material collected at delivery showed edema, muscle fiber degeneration, and fibrosis. These results corroborate the presence of compartment syndrome.
On gross examination, there are no hemorrhages or necrosis. On the microscopic view, there is a diffuse proliferation of uniform fibroblasts and myofibroblasts along with degenerative skeletal muscle fiber and scar-like collagen. It stains positive for Vimentin and actins.
The evaluation of a newborn should include an exhaustive clinical history, the existence or otherwise of a history of oligohydramnios, a traumatic delivery or pelvic presentation, and a thorough physical examination with particular attention to sternocleidomastoid palpation. If the mass is small or missed in the neonatal period, infants usually present with the head tilted and flexed to the side of the lesion.
It may grow for two months until it reaches the approximate size of an almond when it begins to regress and may disappear entirely until the eighth month of life. In older children, the sternocleidomastoid muscle appears thickened and condensed along its length, which leads to restriction of rotation and lateral flexion of the neck. Due to these rotational changes, there can be flattening of the head called positional plagiocephaly. It can correlate with other musculoskeletal abnormalities such as positional musculoskeletal deformities including metatarsus adductus, calcaneovalgus feet, and developmental dysplasia of the hip, brachial plexus palsy.
This position causes asymmetrical pressure on the skull and developing facial bones. This constant pressure on the head can lead to remodeling of the cheekbones and result in facial hemihypoplasia or plagiocephaly. These changes affect proper breastfeeding positioning, making it difficult for the baby to suckle during breastfeeding.
Throughout the child's motor development, language, balance in different positions such as sitting, crawling originates compensations from disparate systems with possible consequences on orthostatic postures, such as scoliosis. Physical examination is the easiest and most effective means of diagnosis. Neurological assessment, as well as auditory assessment, are fundamental to exclude other differential diagnoses.
It is crucial to assess visual function: eye alignment, presence of red reflex, and pupillary reaction to light, to determine whether it fixes and follows objects. Often there may be a weakness of the oculomotor muscles lateral rectus or superior oblique ; the torticollis results from a compensatory mechanism to improve vision. On physical examination, if there is no muscle contracture and joint amplitudes are intact, then this suspicion requires referral to ophthalmology.
Multiple risk factors correlate with a higher incidence of hip dysplasia: female sex, first childbirth, family history of hip dysplasia, the existence of other deformities such as congenital torticollis, birth with a pelvic presentation, cesarean delivery, large fetus. This condition can be bilateral and is most often unilateral.
Early diagnosis of hip dysplasia is of utmost importance. It is an asymptomatic condition in the newborn, in which early detection can be effectively treated, improving the prognosis. Late diagnosis can result in sequelae such as lameness, chronic pain, degenerative arthritis, as well as mental impairment. Thus, appropriate screening for this condition is essential for the clinical signs of hip dysplasia and the need for early diagnosis and, if in doubt, refer to a specialist.
The clinical diagnosis systematically relies on both major and minor clinical signs. The minor signs are Galeazzi sign and asymmetry of the folds inguinal and thighs. Diagnosis is usually made clinically, with few cases diagnosed through the use of complementary diagnostic tests. The most common imaging modality is ultrasonography, especially in the neonatal period. Magnetic resonance imaging MRI can be useful to rule out nonmuscular causes of torticollis.
The swelling is firm, movable under the skin, and soft to the touch. The age of presentation varies with severity: postural is the version that appears earlier. The tumor tends to disappear between 4 and 8 months of age. Histopathologic studies are rarely necessary for instances where the imaging modalities are inconclusive regarding the etiology.
In the early course of the condition, fine-needly aspiration cytology FNAC specimens are an option. Biopsy or surgical specimens have fewer findings since they are obtained in the latter course of the disease. Professionals in various fields, including physiotherapy and osteopathy, recommend techniques for the treatment of infant torticollis. With congenital torticollis, a palpable sternocleidomastoid mass is an important indicator for the intervention to be started by the second month of life, as it influences the child's normal motor development.
The main goal is to achieve an age-appropriate active and passive range of motion of the neck and to prevent contractures and develop symmetry of face and head and neck. Initial treatment focus on passive range stretching and close follow up. Parents are advised to perform positioning at schedules such as during feeds; this includes rotation of the chin towards the affected side shoulder. Infants can be placed on their stomach when awake and under supervision to develop motor skills in the prone position.
Manual stretches such as flexion, extension, the lateral rotation should be done at least three times a week in a set of 15 stretches with each stretch for about a second with a 10 seconds pause in between. If there is a fibrous aspect, stretching techniques are the most essential and most evidence-based treatment.
Although there are a large number of protocol studies in the literature demonstrating the effectiveness of physical therapy, there is little reported data on the frequency and types of exercise.
In many studies, the initial frequency was 2 times per week in the 1st month, progressing to once per week; some authors refer 3 times a week initially. It is recommended for children more than four months of age, and the child can use it when they are awake during day time. Physical therapy is not always effective for treatment, and other resources may be used, such as the adjunctive use of botulinum toxin injection in the sternocleidomastoid other muscles in the region.
Fusion and segmentation osseous abnormalities often correlate with torticollis and other structural abnormalities. There are also neurogenic causes, such as central nervous system tumors, ocular torticollis.
Torticollis in these situations is due to underlying visual or neurologic problems other than sternocleidomastoid abnormalities. Here also, there is a normal neck examination with a full range of motion. To correct the torticollis underlying cause needs to be evaluated and treated. Most cases are benign and resolve spontaneously or with manual stretching. Craniofacial asymmetry is also improved, especially in early treated cases.
Permanent anatomic abnormalities can occur in scenarios where treatment gets delayed or is unavailable. It can be disfiguring and may have cosmetic concerns along with functional impairment.
Positional plagiocephaly is commonly associated with muscular torticollis, and it is essential to be able to differentiate a benign condition like positional plagiocephaly from craniosynostosis. A careful examination of the sutures as well as imaging, either a radiograph or an ultrasound might be necessary to differentiate one from the other.
Congenital muscular torticollis CMT is a rare congenital musculoskeletal disorder characterized by unilateral shortening of the sternocleidomastoid muscle SCM. It presents in newborn infants or young children with reported incidence ranging from 0. Owing to effective shortening of SCM on the involved side there is ipsilateral head tilt and contralateral rotation of the face and chin. It is seen in 0. Numerous theories have been proposed, but the true etiology of CMT remains uncertain.
Es de acceso abierto. The traumatic bone cyst, also called simple bone cyst, hemorrhagic bone cyst, solitary bone cyst and idiopathic bone cavity 1—11 has been described for first time by Lucas in and since then this lesion has attracted great interest in dental literature for its unclear pathogeneses. Other theories include the inability of interstitial fluid to exit the bone due to blockage of drainage system, bone growth and development disorders, ischemic necrosis of medullary bone and local changes in metabolism resulting in bone osteolysis. The World Health Organization rates traumatic cysts as non-neoplastic lesions, because of not having epithelium as true cysts. It usually occurs in the metaphyseal region of long bones and it is unusual in the maxillofacial region, with a prevalence of 0. The definitive diagnosis is mainly based on clinical and radiographic features, 4,9 along with surgical findings.
Metrics details. Congenital muscular torticollis is the third most common congenital musculoskeletal anomaly after dislocation of the hip and clubfoot. When diagnosed early, it is obvious that it can be managed with good or excellent results.
Background : Positional plagiocephaly PP is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis CMT. Few studies have evaluated the efficiency of a manual therapy approach in PP. Read More. Fibromatosis colli, also known as 'sternocleidomastoid tumour of infancy' or 'pseudotumour of infancy', is a rare condition involving fibrosis and swelling, or 'tumour' of the sternocleidomastoid muscle in newborns that typically occurs after a traumatic delivery.
Torticollis, also known as a twisted neck, is the contraction or contracture of the muscles of the neck that causes the head to tilt to one side. It is accompanied by rotation of the chin to the opposite side with flexion. Usually, torticollis is not a diagnosis but rather a manifestation of a variety of underlying conditions. It can be congenital or due to acquired causes.
Metrics details. Congenital muscular torticollis CMT is due to contracture of the sternocleidomastoid muscle which may cause activity limitations of the neck, tilt of the head, craniofacial asymmetry, and deformity of the skull. The authors present their experience of arthroscopic tight fibrous band release with radiofrequency in teenagers under local anesthesia and evaluate the clinical results. A total of 69 patients who underwent arthroscopic release of CMT with radiofrequency under local anesthesia by a single surgeon could participate in this study. Before operation, surface landmarks of sternocleidomastoid muscle, bone, and neurovascular structures were marked.
Atlas of Pediatric Surgery pp Cite as. Torticollis is characterized by tilting and rotation of the head and neck as a result of fibrosis and contracture of the sternocleidomastoid muscle. The clinical features, etiology and management are discussed.
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