Torticollis

Torticollis is an abnormal, sustained tilting or twisting posture of the head and neck. It results from unilateral shortening or spasm of the neck musculature, most commonly the sternocleidomastoid muscle.

Causes range from benign, self-limiting congenital muscular torticollis in infants to acute, acquired torticollis in older children and adults. Acquired torticollis is frequently benign and self-limiting, though occasionally it reflects a serious underlying cause requiring urgent identification.

Accurate diagnosis requires careful attention to age of presentation, mode of onset, and associated features. The differential diagnosis and the urgency of assessment differ substantially across these clinical contexts.

Classification and pathophysiology

• Congenital muscular torticollis is the commonest cause in infancy. It reflects fibrosis and shortening of the sternocleidomastoid muscle, believed to result from intrauterine positioning or perinatal trauma to the muscle.
• A firm mass within the muscle belly is sometimes palpable in the neonatal period. It is termed a sternocleidomastoid "tumour" or "pseudotumour" and reflects localised fibrous thickening rather than any genuine neoplastic process.
• The result is the characteristic head tilt toward, and chin rotation away from, the affected side.
• Acute acquired torticollis in older children and adults has a range of causes. Benign mechanical or muscular causes include muscle spasm after minor trauma or sustained awkward positioning, sometimes termed "wry neck".
• Atlantoaxial rotatory subluxation is an important cause, particularly in children. It often follows relatively minor trauma or an upper respiratory tract or retropharyngeal infection.
• Inflammatory laxity of the supporting ligaments leads to rotational subluxation at this cervical spine level, which is sometimes self-limiting.
• More serious causes need urgent consideration and exclusion. Posterior fossa tumour is one: torticollis is a recognised, sometimes early feature, reflecting cerebellar tonsillar irritation or direct compression of relevant structures.
• Retropharyngeal abscess is another. Dystonic drug reaction is a third, because acute dystonic reactions to dopamine receptor blocking medications frequently produce torticollis as part of the broader dystonic presentation.

• Congenital muscular torticollis typically presents within the first few weeks of life. There is a characteristic head tilt toward the affected side and chin rotation toward the opposite, contralateral side.
• In a substantial proportion of cases there is a palpable, firm, non-tender mass within the affected sternocleidomastoid muscle. It characteristically resolves spontaneously over weeks to months as the initial muscular fibrosis settles.
• The underlying muscular shortening and torticollis may persist, or require specific treatment, if not managed proactively.
• Acute acquired torticollis presents with sudden or rapidly developing abnormal head and neck posturing, often with significant pain and muscle spasm. The clinical context and associated features guide diagnosis.
• A preceding minor trauma or sustained awkward positioning (such as a prolonged, unusual sleeping posture) supports a benign, mechanical or muscular cause.
• A preceding upper respiratory tract or pharyngeal infection supports atlantoaxial rotatory subluxation, especially with reluctance to move the neck and a characteristic "cock-robin" head position (head tilted to one side, rotated to the other, and slightly flexed).
• Red flag features need urgent investigation and exclusion of a serious underlying cause. They include torticollis developing gradually and progressively over weeks rather than suddenly.
• Neurological symptoms or signs raise concern for a posterior fossa mass lesion: headache, particularly if worse in the morning or with straining, ataxia, or any focal neurological deficit.
• Significant fever and systemic upset raise concern for retropharyngeal or other deep neck infection.
• Recent exposure to a dopamine receptor blocking medication raises concern for an acute dystonic drug reaction.
• Assess carefully for these red flags and perform a thorough general neurological examination in any child or adult with acute torticollis. This separates the generally benign, self-limiting causes from the less common serious causes that need urgent evaluation and treatment.

• Congenital muscular torticollis is generally diagnosed clinically from the characteristic presentation and examination findings.
• Ultrasound of the affected sternocleidomastoid muscle can characterise and confirm the localised muscular thickening where there is diagnostic uncertainty. It is not routinely required in a straightforward, typical presentation.
• Assessment of acute acquired torticollis is guided by the presentation and any red flag features.
• Use plain radiography or, where suspicion of atlantoaxial rotatory subluxation is significant, dedicated cervical spine imaging.
• Dynamic or computed tomography imaging is sometimes required to confirm the diagnosis, because standard plain radiography is limited in reliably demonstrating this abnormality.
• Magnetic resonance imaging of the brain and cervical spine is essential where there is any suspicion of a posterior fossa mass lesion, based on red flag features (progressive onset, associated neurological symptoms or signs). Prompt identification or exclusion of this serious cause is critical.
• Direct further targeted investigation by the presentation and suspected cause identified at initial clinical assessment. This includes relevant blood tests and, where retropharyngeal or other deep neck infection is suspected, contrast enhanced computed tomography of the neck.

• Congenital muscular torticollis is managed with structured physiotherapy. It comprises passive stretching exercises of the affected sternocleidomastoid muscle and positioning strategies. The infant is encouraged to turn the head actively toward the affected side during feeding, play, and supervised tummy time.
• This conservative approach resolves the condition in the great majority of affected infants when started promptly and performed consistently.
• Reserve surgical release of the affected muscle for the small minority with persistent, significant torticollis despite an adequate trial of physiotherapy. It is generally considered from around age one year if conservative management has been inadequate.
• Benign, mechanical acute torticollis (muscle spasm or "wry neck") is managed conservatively with simple analgesia, gentle heat, and gradual, gentle mobilisation as tolerated. It generally resolves spontaneously over several days.
• Atlantoaxial rotatory subluxation is managed according to duration and severity. Shorter duration subluxation is managed conservatively with soft collar immobilisation, analgesia, and muscle relaxants.
• More prolonged or severe cases need structured cervical traction under close specialist orthopaedic or spinal surgical guidance to achieve reduction. A period of immobilisation follows to support stability and prevent recurrence.
• Dystonic drug reaction related torticollis is managed with anticholinergic treatment (procyclidine or benztropine), detailed under oculogyric crisis. The underlying mechanism is shared and the response to this treatment is typically rapid and effective.
• Manage suspected or confirmed retropharyngeal abscess or other deep neck infection according to standard principles for the underlying condition.
• Any posterior fossa mass lesion needs urgent neurosurgical referral and management according to the underlying pathology.
• The causes are broad and a small proportion of presentations reflect a serious underlying condition. Use a structured, systematic approach with careful attention to age, mode of onset, and red flag features.
• Keep a low threshold for further targeted investigation where these concerning features are present. This underpins safe, effective management across all ages and causes.