WRY NECK IN A CHILD : TORTICOLIS
Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
Some children are noticed to have wry neck at or soon after birth. Usually, there has been a breech delivery and this has often(wrongly) been blamed as the cause. There is an angling of the neck so that the child is looking upwards and to one side. The child is always in this position and it is not possible to correct the deformity manually. With age and without any treatment, this will increase and not only will the child look odd, but additionally, there will be a loss of development of that side of the face called facial hypoplasia. Again, because the child is used to looking at persons & objects with the head bent, gradually the child will also develop a double vision as the 2 eyes have a different axis.
Torticollis with short left side muscle
A detailed examination of the child will reveal a small rounded mass on the right or left of the midline low in the neck. This is called “Sternomastoid Tumor” as this is a mass found in the muscle called sternomastoid. This is usually a fibrous tissue mass at the lower end of the muscle thus effectively shortening the length of the muscle. The 2 ends of the muscle come nearer to each other and since this muscle is angulated from the lateral to the medial side, this pulls that side of the head downwards and pulls it to the opposite side. In children with this obvious deformity, it is always essential to rule out any abnormalities of the cervical vertebrae – either partially formed, abnormal placement or growth etc. Hence taking of plain x rays of the cervical spinal column is a must before labeling it as simple torticollis.
Therapy for this condition can be simple if detected and shown to the correct doctor at the earliest. Having noticed it at birth, this child must be shown to a Pediatric Surgeon soon after. The ideal mode of therapy is based on the principal that this defect is due to shortening of the muscle and we have to gradually stretch and lengthen the muscle if possible. This is done by passive physiotherapy. This is taught to the parents of the child. The child is held by one parent with both arms by the side to stabilize the shoulders. The child is held on the edge of the bed or cot so that only the head is beyond the edge and is free. The other parent holds the head of the child and gradually and carefully is made to move the head in 6 different directions one after the other. The directions are touching the chin to the chest – flexion and then the opposite direction – extension of the neck. The other 2 are lateral – make the childs face turn towards the right side , then to the left side. The last 2 directions are bend the childs head such that the ear on one side touches the same side shoulder. The range of the movement is very minimal to start with, and is gradually increased. This passive exercise is done by the parents twice a day, and will continue till the child is able to hold the head without any angulation. Along with physiotherapy, a cervical collar is made to order for the child. This is an atypical collar –that is stiff, padded to avoid any sharp /edge that may hurt the child , and the distance from the angle of the jaw to the clavicle is more on the side of the deformity – this will hold the neck in the overcorrected position at all times. The collar has to be worn during the day at all times, but should be removed at night. In about 90% of children this treatment works very well and no further therapy is required later.
However, in some children who are not treated correctly after birth, or who are seen by the correct person late may not give the same result. Many of these children already have either a unilateral facial hypoplasia or double vision and it is wiser not to try the above therapy and go for surgical correction at the earliest.
Muscle dissected and cut
This surgery is done under general anesthesia, the shortened muscle is exposed at its lower end near the clavicle and the tendon of the muscle is isolated, and cut to release the shortening and allow the 2 ends to move apart. This way the length of the muscle is artificially increased to equal that on the opposite side. The incision is closed and a dressing is given.
Post operative day 7- tilt already less
The previously talked about collar is then applied to the neck of the child to hold it in the over corrected position for a few weeks. After 7 days of surgery, the wound dressing is removed and the incision is kept open.
Physiotherapy is begun gradually and the range of neck movement is increased to maximum over a period of 4 –6 weeks. As the child grows, the facial hypoplasia and the dual vision will disappear. This surgery also can be done as a day care case. The child is able to go home on the same day of operation and come back for follow up. Thus, in this condition, surgery is the last option when other treatment fails and should rarely be required if detected, shown and treated in time.
Last Updated: 27th January 2009