Congenital muscular torticollis has been known since ancient times and has been described by Horace and Suetonius. Pathology develops as a result of dysplastic changes in the sternocleidomastoid muscles and takes the second place among the most common congenital childhood defects, the percentage of its occurrence is up to 12%.
Causes
There is an opinion that the reason for the development of muscle torticollis lies in the fact that the child’s head occupies a forced position in the uterus due to the entanglement of the neck with an umbilical cord, birth defects, dystrophic, inflammatory processes in muscle tissues (ischemia, interstitial myositis, and others).
The presence in the muscle of a swelling of the spindle-shaped type is considered as a hemorrhage arising from the passage of the baby’s head through the birth canal, due to tears, excessive stretching of dysplastic muscles.
Symptoms, forms
The clinical manifestations of congenital muscle torticollis depend on its shape and age of the child. Specialists classify mild, moderate, severe forms of the disease.
Often, light and medium forms of torticollis are not diagnosed by specialists.
Children receive treatment when organic changes in the facial skeleton are manifested. Severe forms of pathology are easily diagnosed. Typical symptoms of congenital torticollis:
- The child keeps his head tilted to the side.
- The chin is turned in the opposite direction from the tilt of the head.
Passive attempts to return the head to a straight position are unsuccessful due to the fact that the sternocleidomastoid muscles are significantly tense.
In the middle third of the muscle, a spindle-shaped thickening is felt and visualized, which is located in the abdomen of the muscle and does not fuse with adjacent tissues.
As the child grows, symptoms begin to increase, muscle elasticity decreases.
After a year of life, an asymmetry of half the skull and facial skeleton appears on the side where the head is tilted.
Asymmetries of the face
In children of 3 years, asymmetries of the face are clearly visible. The shoulder blades and shoulders are also asymmetric, on the torticollis side they are slightly higher than on the other side.
Muscle hypotrophy is observed in comparison with the healthy side, excluding the middle third, where a thickening of the fusiform shape is palpated.
The asymmetry of the shoulder blades and shoulder girdle is caused by contracture of the anterior scalene and trapezius muscles. In older children, upper thoracic and cervical scoliosis from the side of torticollis begins to develop.
Examination of the child allows you to clearly determine the presence of facial asymmetry from the torticollis, as there is a narrow eye socket, a flattened superciliary arch, located somewhat lower than on the healthy side.
Underdevelopment and flattening of both jaws
In addition, underdevelopment and flattening of both jaws is noted. From the torticollis, the ear lobe is located closer to the shoulder girdle.
The main task of doctors is to diagnose muscle torticollis in the hospital and eliminate the pathology until the child reaches one year old. This will prevent the development of deformation of the head and skeleton of the face.
Differential diagnosis
It is necessary to differentiate congenital pathology primarily from the congenital additional wedge-shaped vertebra in the cervical spine.
A wedge-shaped congenital vertebra differs from a torticollis in that the child’s head in this case is tilted to the side, but the chin is not turned in the opposite direction.
In addition, an attempt to move the head to a normal position allows you to detect an obstacle, and there is no tension on the sternocleidomastoid muscle - it remains relaxed. This is the main difference between torticollis.
Also, congenital muscle torticollis should be differentiated from spastic, which is often manifested in cerebral palsy. In the case when cerebral palsy is manifested by typical symptoms, a diagnostic error does not occur. Diagnostic errors occur if the cerebral palsy is erased. To prevent the wrong diagnosis allows a thorough examination of the child.
In addition, differential diagnosis is performed to distinguish congenital torticollis from polio resulting from polio. In such cases, paresis or muscle paralysis develops. Congenital does not cause muscle paralysis, limb muscle paralysis is also absent.
It is also necessary to differentiate muscle torticollis in children from dermatogenic torticollis resulting from injuries, burns.
There is also such a pathology as desmogenic torticollis, which occurs against the background of inflammation in the neck (lymphadenitis, phlegmon).
Differentiation is also required from reflex crankshaft resulting from inflammatory processes in the middle ear. In this case, a careful examination of the patient is necessary, a thorough history taking.
Clippel-File Syndrome
Klippel-File syndrome is a congenital malformation of the vertebrae in the cervical region. In some cases, the epistrophy and atlas merge with the vertebrae located below, while there is no fusion of their arches. In other cases, there is synostosis of the atlas and the occipital bone, while all the vertebrae of the neck are fused together by cervical ribs or additional sphenoid vertebrae.
Such children have a clinically short neck, and the impression is that the head is spliced ​​with the body. At the same time, the position of the limit of the scalp is so low that the transition of the scalp to the shoulder blades is observed. The head in this case is tilted to the side and forward, the chin is in contact with the chest, there is a pronounced asymmetry of the skull, face. There are no movements in the cervical spine.
In older children, kyphosis or scoliosis develops, an asymmetrical position of the shoulder girdles, a high location of the shoulder blades. There are paralysis, paresis, sensitivity disorders in the upper limbs. The presence of this symptomatology allows us to judge the absence of a congenital torticollis.
It is also necessary to differentiate congenital muscular torticollis (ICD 10 - Q68.0) from cervical ribs, which manifest as swelling in the supraclavicular region and impaired neurovascular conduction in one (with unilateral pathology) or both (with bilateral pathology) hands - paralysis, paresis, disappearance of the pulse, impaired sensitivity, skin changes, cold snap.
Bilateral cervical ribs cause low prolapse of the shoulders. It seems that the shoulders continue to neck. At the same time, a side inclination of the head is noted, scoliosis of the cervicothoracic spine is manifested.
A thorough examination, examination, and a full medical history will allow to exclude the occurrence of a diagnostic error.
Shereshevsky-Turner Syndrome
Also, muscle torticollis (ICD 10 - Q68.0) should be differentiated from the pterygoid neck (Shereshevsky-Turner syndrome).
This congenital defect is clinically manifested by the formation of unilateral or bilateral skin folds on the lateral surface of the neck.
Often, the pterygoid neck is combined with other congenital pathologies - flexion contracture of the fingers, hip dislocation, dysplasia.
Examination of the newborn allows you to detect stretched skin folds located on the side of the neck from the middle of the shoulder girdle to the mastoid process. The congealing of the child’s face, deformation of the auricles, and a short neck are also observed. Such symptoms are absent in congenital crankshaft.
It should also differentiate pathology from Grizzle torticollis. This disease always arises as a result of the inflammatory process in the nasopharynx, tonsils, accompanying high fever. In this case, the inflammation extends to the atlanto-epistrophic joint, resulting in a subluxation of the atlant. Such a disease occurs most often in girls of 6-11 years old, having an asthenic constitution and a developed lymphatic system, through which the infection spreads.
The clinical manifestations of Grisel's torticollis are as follows: the head has a side inclination and is turned in the opposite direction, palpation allows you to detect the protrusion of the spinous process of C11. Examination of the pharynx reveals the presence of a protrusion on its posterior-upper surface at the level of the atlas, which is somewhat shifted up and forward. This protrusion changes its size when the child turns his head.
The tilt of the head, extension and bending of the neck towards torticollis occurs freely, in the opposite direction it is very limited, causing pain.
Rotational head movements are limited, cause pain, occur in the lower vertebrae of the cervical region. An X-ray photograph with Grisel torticollis should be taken through the mouth. This will allow us to diagnose the subluxation of the atlas and its rotation around the vertical.
Therapy
Treatment for muscle torticollis should begin after the umbilical ring fusion occurs. The mother should ensure that in bed the child lies on the side of the curvature, and the pillow should deflect the head in the opposite direction.
Treatment of muscle torticollis is important to start in a timely manner.
It is also necessary to put the bed so that the toys and the light are on the opposite side of the crank. In this case, the child will turn his head, stretching the dysplastic muscle.
Permanent correction of the head with muscle crankshaft involves the use of first cotton-gauze pads, placed on the side of the torticollis, and then (1 month of life) - Shants collar, applied after the reduction. Redress should be carried out up to 5 times a day, each of them should take up to 15 minutes. By the time of discharge from the maternity ward, the mother should learn the technique of redress.
Redress
The child must be laid on the table, on his back, placing his hands along the body. They are held by a mother or assistant.
The doctor approaches the child from the side of the head, puts both palms on the cheeks and head and tries to bring her to a normal position with increasing strength, but smoothly, while turning her chin to the side of the torticollis.
This position allows you to maximize the dysplastic muscle. It is important to ensure that during the redress the child’s head does not lean forward.
Reduction is carried out to treat congenital muscle torticollis within 5-10 minutes. Up to 5 procedures should be performed per day. After it, the head is fixed with cotton-gauze pads, fixed with a bandage, in the most corrected condition.
After the baby has finally formed the skin (2.5-3 months from birth), paraffin applications are prescribed to thicken the dysplastic muscle and improve its elasticity.
After the child reaches 2 months, you can start using the Shants collar to fix the head.
Therapy is carried out, gradually stretching the muscle to completely eliminate torticollis until the age of one. This approach is almost always effective for muscle crankshaft of mild and moderate forms.
Surgery
It is not always possible to completely correct muscle torticollis in infants with severe forms, therefore, at the age of 10-12 months, the child is prescribed surgery.
An operation performed at this age helps prevent the occurrence of facial deformities.
Manipulate under anesthesia. The child is placed in a supine position, the surgeon's assistant maximally aligns the position of the head, as a result of which the legs of the muscles are pulled.
In parallel with the tense muscles above the clavicle, the skin and soft tissues are cut, the sternal and clavicular muscle legs are secreted, the defenders are alternately brought under them, and then they are cut. Then carefully cross the posterior wall of the tendon sheath.
Another incision is made over the mastoid process, the onset of the muscle is isolated, it is transversely crossed at the beginning.
After that, the child’s head is brought into a hyper-correcting position, both incisions are sutured, an aseptic dressing is made and a Shants collar is applied. It is important that the head is fixed in a hypercorrection position.
What other treatment for congenital muscle torticollis can be carried out?
If the child is 8-9 years old, then he is recommended to apply a thoraco-cranial plaster cast. After 2 weeks should begin physical therapy. Shantsa collar should be applied within 3 months after each exercise therapy session. With proper treatment and rehabilitation, there is a restoration of strength, performance, muscle endurance, as well as a stable position of the head. It is important to follow all the doctor’s recommendations, this will allow you to adjust the pathology on time and prevent deformation of the face in the child.
Massage with muscle torticollis is an effective treatment method and should be prescribed by a doctor. The objective of this procedure is to activate blood circulation and lymph flow, as well as to promote muscle relaxation where they are clamped. Massage sessions will help them take a natural position.