Congenital Torticollis

Congenital torticollis is usually diagnosed within the first month of life. Diagnosis after 6 months is rare and other causes should be considered. 

There are 2 types:

• Muscular: Tightness of the sternocleidomastoid (SCM) muscle and limitation of passive range of motion. This is the most common type Muscular with SCM mass: Thickening of the SCM muscle and limitation of passive range of motion
• Postural: Infant has a preferred head posture but no muscle tightness or restriction to passive range of motion

Muscular torticollis is most common. If the examination supports a diagnosis of congenital muscular torticollis, no further investigations are required. Congenital torticollis is a postural deformity of the neck that develops prenatally. 

Assessment of Congenital Torticollis

Congenital muscular torticollis should be suspected in infants with following red flag signs…

• Preferred head position or posture
• Reduced range of motion of the cervical spine
• SCM mass  and/or
• Craniofacial asymmetry. 

History

• Onset: Noticed at birth or shortly after supports diagnosis
  • Torticollis diagnosed after 6 months should prompt consideration of acquired causes.
  • Acute onset torticollis should prompt further 
• Infants may have difficulty feeding on one side
• Time spent in prone position (lack of tummy time may contribute to persistence)
• Developmental milestones, especially gross motor, may be delayed

Examination

• Head position: The head and ear are tilted toward the affected SCM and the chin points to the opposite side
• Normal passive neck movements: When stabilised in the supine position, the examiner should be able to passively rotate the chin past the shoulders and laterally flex the neck so that the top of the ear touches the shoulder. Limitation suggests torticollis
• Palpate for tightening or SCM mass: The characteristic SCM mass is well circumscribed, firm and found in the inferior one-third of the affected SCM
• Head shape and sutures (plagiocephaly and facial asymmetry are common)
• Eye movements, back and spine, upper and lower limbs and a neurological examination should be performed to identify rare non-muscular causes 
• Note that Developmental Dysplasia of the Hip (DDH) is a common association and hips should be assessed

Differential  Diagnosis 
Consider an alternative diagnosis if no muscle tightness or mass is palpated on examination

Rarely congenital torticollis may be secondary to vertebral anomalies, clavicle fractures, plagiocephaly, craniosynostosis, ocular pathology or CNS lesions

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