congenital muscular torticollis current concepts and review of treatment pdf

Congenital Muscular Torticollis Current Concepts And Review Of Treatment Pdf

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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.

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.

Congenital muscular torticollis

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. Various causes implicated for CMT includes intrauterine crowding or vascular phenomenon, fibrosis from peripartum bleeds, compartment syndrome, primary myopathy of the SCM and traumatic delivery.

When diagnosed early, CMT can be managed conservatively, seldom requiring surgery. In children older than 1 year, corrective surgery has both cosmetic and functional benefits, the best outcomes being obtained between the ages of 1 and 4.

On examination head tilt to the right with chin deviation to the left was noted [ Figure 1 ]. There was a significant restriction of neck movement, especially on lateral rotation. There was no obvious facial asymmetry. On palpation right SCM muscle was non-tender, taut and cord like.

No lump or mass could be palpated along the entire muscle length. Systemic evaluation revealed no abnormality. Radiographs of the cervical spine, hips and lower extremities were normal. No neurological or ophthalmologic deficit could be elicited. Based on the above findings, a clinical diagnosis of CMT was established.

Preoperative clinical photograph showing the child with congenital muscular torticollis affecting the right sternocleidomastoid muscle. Physiotherapy was started for the patient to achieve SCM muscle stretching. However, after 8 weeks of exercise, there was no improvement in the condition. Subsequently release of unilateral SCM by bipolar tenotomy was planned. Patient was prepared and taken up for the surgery under general anesthesia.

A 2 cm incision was made below the mastoid on the right side. The attachment of SCM muscle to mastoid bone was identified and completely stripped from its bony attachment, protecting the underlying vital structures and overlying greater auricular nerve.

A transverse incision of about 2. Both the heads of SCM were identified and then divided under direct vision together with deep fascia. The muscle was allowed to retract. Complete neck extension was achieved without any strain [ Figure 2 ].

Intraoperative photographs. Sternal end was then sutured to the clavicular cut end in an oblique line to achieve muscle lengthening. Patient was immobilized in the corrected position with adjustable torticollis brace from third postoperative day [ Figure 3 ]. Simultaneously, the patient was referred to physiotherapist and a rigorous regimen of exercise involving head and neck manipulation through the full range of motion was given for a period of 12 weeks, 3 times every week.

Patient at 12 months review shows the complete range of head and neck movements with no head tilt and neck stiffness [ Figure 4 ]. At 12 months postoperative photographs showing straight neck with a normal range of neck movement.

It is also sometimes referred to as wry-neck, stiff-neck, caput obstipum, crooked-neck and twisted-neck. The reported incidence of CMT varies from 0. The right side was more commonly affected. Prominent theories behind SCM muscle impairment in CMT include intrauterine crowding, muscle trauma during a difficult delivery, soft-tissue compression leading to compartment syndrome and congenital abnormalities of soft-tissue differentiation within the SCM muscle.

Histologic studies of resected surgical specimens have demonstrated edema, degeneration of SCM muscle fibers and fibrosis. The most common presentation of child with CMT is a head tilt toward the affected side and the chin pointing to the contralateral side. With continued unilateral weight bearing, the skull base and cranium deform so that the vertex view reveals a parallelogram shaped head. If not treated it may lead to craniofacial growth deformity in adult.

Children with CMT can be subdivided into three clinical subgroups. Group 1 is the sternocleidomastoid tumor group, which consists of torticollis with a palpable pseudotumor or swelling in the body of SCM. This is a hard, movable mass within the substance of the SCM noted at birth.

This mass is usually located in the middle to lower third of the sternal portion of SCM. The pseudotumor usually becomes large after its first noted and then slowly resolves over a period of months.

This is the most common presentation and contributes to Though SCM contracture is the most common cause of torticollis in children, other congenital and developmental causes should be ruled out. Other causes of torticollis in children have been classified as osseous occipitocervical dysfunction, cervical vertebral dysfunction , nonosseous Sandifer syndrome and neurogenic central nervous system tumors, ocular torticolis.

Ultrasound is the imaging modality of choice for radiographic evaluation of CMT. The normal SCM on ultrasound presents as a hypoechoic mass with echogenic lines, indicating muscle fascicles running throughout its length. The presence of a SCM tumor affects not only the size of the muscle noted on ultrasound, but also its signal intensity.

CMT muscles tend to be more hyperechogenic. Treatment of infants with torticollis is guided by the age of infant, the severity of torticollis, the diagnosis of plagiocephaly and the presence of associated neuromuscular or orthopedic impairment.

Early physical therapy is initiated if there is any lack of rotation from fibrosis. During the manual stretching, a snapping sensation may be heard and felt. Despite the muscle trauma, patients still do remarkably well. Cervical collars could be necessary adjuncts used to restrain the neck in its normal position.

Active physiotherapy regimen as described above was given for our patient preoperatively. However, the deformity did not improve and was persistent, prompting us to plan for surgical release of the SCM muscle.

Bipolar release of SCM was planned for our case looking at the resistant nature of the deformity after physiotherapy and age of the patient. Postoperatively, the patient was put on torticollis braces and active physiotherapy regimen to prevent relapse and maintain the normal range of neck movement.

At 12 months review, the patient showed complete range of the head and neck movements with no head tilt and neck stiffness. Besides physiotherapy and surgery or combination of both, other treatment modalities have also been reported. Joyce and de Chalain[ 15 ] have published their intermediate follow-up of treatment of recalcitrant CMT by botulinum toxin Botox. Botox could enhance the effectiveness of stretching of SCM on the side of contracture and allow strengthening of the overstretched and weakened muscle on the opposite side of the neck.

Although Botox has promising potential, it carries the risk of systemic diffusion, hematoma formation, as well as neck pain. In CMT, early diagnosis and physical therapy result in the best outcome. However, for resistant cases or in those treated after the age of one, surgical lengthening or release of SCM Muscle is necessary. Source of Support: Nil. Conflict of Interest: None declared.

National Center for Biotechnology Information , U. Journal List Ann Maxillofac Surg v. Ann Maxillofac Surg. Kumar Nilesh and Srijon Mukherji 1. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Congenital muscular torticollis CMT is a rare congenital musculoskeletal disorder characterized by unilateral shortening of the sternocleidomastoid muscle SCM.

Keywords: Congenital, sternocleidomastoid muscle, tenotomy, torticollis. Open in a separate window. Figure 1. Figure 2. Figure 3. Figure 4. Tubby AH. London, England: MacMillan; Deformities and Diseases of Bones and Joints; p.

Pseudotumor of infancy and congenital muscular torticollis: cases. Congenital muscular torticollis: Sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop. Sternocleidomastoid pseudotumor of infants and congenital muscular torticollis: Fine-structure research. Congenital muscular torticollis and the associated craniofacial changes.

Plast Reconstr Surg. Infantile torticollis: A review of cases. Colonna P.

Congenital muscular torticollis: current concepts and review of treatment.

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. Although usually self-limited, fibromatosis colli can lead to congenital muscular torticollis and positional plagiocephaly due to uneven forces on the neonatal skull. Ultrasound is the diagnostic imaging modality of choice and can prevent additional imaging and unnecessary intervention.

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.

A Surgical Treatment for Adult Muscular Torticollis

Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: Do Published Medicine Current opinion in pediatrics.

Neglected or undiagnosed congenital muscular torticollis in adults is quite rare, although it is the third most common congenital deformity in the newborn 1.

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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. Various causes implicated for CMT includes intrauterine crowding or vascular phenomenon, fibrosis from peripartum bleeds, compartment syndrome, primary myopathy of the SCM and traumatic delivery. When diagnosed early, CMT can be managed conservatively, seldom requiring surgery.

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. The aim of this prospective study was to determine the efficacy of surgery in neglected adult cases. From January to June , 18 adult skeletally matured patients were surgically treated for neglected congenital muscular torticollis and prospectively followed at least one year. Bipolar release was performed in all patients.

Adult presentation of neglected congenital muscular torticollis CMT is rare. Therefore, efficacy of surgical treatment for adult CMT is unclear. We experienced a case of neglected CMT in a year-old male patient and report the surgical result here. We conducted unipolar resection at the distal end of the sternocleidomastoid muscle SCM. After surgery, the range of neck movement and head tilt improved, and his appearance was cosmetically improved despite the long-standing nature of the deformity.

Endoscopic release of congenital muscular torticollis with radiofrequency in teenagers

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