Torticollis: Symptoms, Types, Causes and Treatment

Torticollis, often referred to as "wry neck," is a condition that affects people of all ages, from infants to adults. Characterized by an abnormal, twisted posture of the head and neck, torticollis can arise suddenly or develop gradually, causing discomfort, pain, and sometimes significant functional impairment. Understanding its symptoms, various types, underlying causes, and available treatments is essential for timely recognition and effective management. In this comprehensive article, we will explore these aspects in detail, guided by current research and clinical guidelines.

Symptoms of Torticollis

Torticollis can present in a variety of ways, but its hallmark is an abnormal positioning of the head and neck. Recognizing these symptoms early can make a significant difference in treatment outcomes, especially in infants and children. Below is a concise summary of the key symptoms typically observed.

Posture	Muscle Involvement	Associated Features	Source(s)
Head tilt	Sternocleidomastoid spasm	Chin rotation opposite	1, 2, 6
Limited ROM	Neck muscles	Neck pain, stiffness	1, 6, 7
Neck pain	Variable	Tenderness, spasm	6, 7
Secondary	May involve other muscles	Headaches, dizziness	1, 7

Table 1: Key Symptoms

Typical Presentation

Torticollis is most commonly recognized by a distinct head posture: the head tilts to one side while the chin rotates to the opposite side. This is due to the contraction or spasm of the sternocleidomastoid muscle, although other neck muscles can also be involved 1, 2.

Range of Motion & Pain

Often, there is a noticeable limitation in the neck’s range of motion. Attempting to move the head in the opposite direction may cause discomfort or acute pain. In children, this may present as irritability or reluctance to turn the head 6, 7.

Associated Features

Depending on the underlying cause and duration, other symptoms may emerge:

• Muscle tenderness and palpable tightness in the neck.
• Headaches or even dizziness, especially if torticollis persists or if neurological causes are involved 1, 7.
• In infants, the condition may lead to facial asymmetry or changes in head shape over time if not addressed 4, 11.

Secondary Complications

Chronic or untreated torticollis may result in:

• Musculoskeletal sequelae such as jaw, vision, or chewing problems 4.
• Developmental delays or neurodevelopmental issues, particularly in severe congenital cases 4, 11.

Types of Torticollis

Torticollis is not a single disease but a clinical sign with various subtypes. An accurate understanding of its classification helps guide diagnosis and therapy. Here is a summary table of the main types.

Type	Age Group	Defining Feature	Source(s)
Congenital muscular	Infants	SCM contracture, birth onset	1, 2, 4
Acquired	All ages	Trauma, infection, tumor	1, 7
Spasmodic	Adolescents/Adults	Dystonia, involuntary spasm	2, 5, 8
Ocular	Children	Eye muscle weakness	1, 2

Table 2: Major Types of Torticollis

Congenital Muscular Torticollis

This is the most common form in infants, characterized by unilateral shortening or fibrosis of the sternocleidomastoid muscle (SCM). It commonly presents shortly after birth, leading to the classic head tilt/chin rotation 1, 2, 4. Early recognition is crucial for preventing long-term complications 4, 11.

Acquired Torticollis

Acquired torticollis can develop at any age and has a wide range of causes. It is often related to trauma, infection, inflammation, or underlying neurological conditions. It tends to present suddenly in previously healthy individuals 1, 6, 7.

Spasmodic Torticollis (Cervical Dystonia)

This type is more common in older children, adolescents, and adults. It results from involuntary muscle contractions, often with twisting or jerking movements. The condition may be idiopathic or have a genetic component (e.g., DYT7 gene) 2, 5, 8.

Ocular and Other Rare Types

Ocular torticollis is due to eye muscle weakness or visual disturbances, prompting compensatory head posture. Other rare forms include "benign paroxysmal torticollis" (episodic, in infants) and those associated with syndromes like Sandifer's (linked to gastroesophageal reflux) 1, 2.

Classification by Dynamics

Some experts classify torticollis as nonparoxysmal (persistent) or paroxysmal (episodic/dynamic), depending on how symptoms fluctuate 2.

Causes of Torticollis

The underlying causes of torticollis are diverse and age-dependent, ranging from muscular to neurological and even psychiatric origins. The table below summarizes the main causes.

Etiology	Age/Affected Group	Example/Trigger	Source(s)
Muscular	Infants, all ages	SCM contracture, trauma	1, 2, 4
Osseous	Children, adults	Cervical spine anomaly	1, 2
Neurological	All ages	Tumor, dystonia, ADEM	1, 7, 5
Inflammatory/Infective	Children	URTI, abscess, adenitis	6, 1
Ocular	Children	Strabismus	1, 2
Psychiatric	Children, teens	Conversion disorder	2, 7

Table 3: Major Causes of Torticollis

Muscular Origins

• Congenital Muscular Torticollis: Most commonly, this results from fibrosis or tightness of the SCM muscle, often noticed in newborns 1, 2, 4.
• Trauma/Soft Tissue Injury: Can occur at any age due to accidents or sudden movements 1.

Osseous (Bony) Causes

• Cervical Spine Abnormalities: Congenital anomalies or acquired injuries affecting the cervical vertebrae can produce torticollis 1, 2.
• Atlantoaxial Rotatory Subluxation: Especially in children following trauma or inflammation (e.g., Grisel’s syndrome) 1, 6.

Neurological Causes

• Central or Peripheral Nervous System Disorders: Conditions such as acute disseminated encephalomyelitis (ADEM), tumors (e.g., posterior fossa), or cervical dystonia can manifest as torticollis 1, 7, 5.
• Genetic Factors: Adult-onset idiopathic cervical dystonia may be linked to mutations such as DYT7 5.

Inflammatory and Infectious Causes

• Upper Respiratory Infection (URTI), sinusitis, otomastoiditis, and cervical adenitis can all lead to inflammatory torticollis, particularly in children 6.
• Retropharyngeal Abscess/Cellulitis: Deep neck infections can irritate neck muscles and nerves, resulting in acute torticollis 6.

Ocular Causes

• Eye Muscle Weakness/Strabismus: Children may develop a compensatory head posture to correct visual misalignment 1, 2.

Psychiatric and Other Causes

• Conversion Disorder: Rarely, psychological factors can result in functional torticollis without organic pathology 2, 7.
• Drug-induced: Certain medications can cause acute dystonic reactions mimicking torticollis 2.

Treatment of Torticollis

Treatment strategies for torticollis depend on age, type, underlying cause, and severity. Early intervention, especially for infants, can prevent long-term complications. Here is a summary of the main therapeutic approaches.

Approach	Indication/Type	Effectiveness	Source(s)
Physical therapy	Congenital, mild acquired	High in infants, first-line	1, 4, 11
Stretching/massage	Congenital muscular	Comparable effects	11, 12
Surgery	Refractory, severe cases	For persistent or structural	1, 8
Botulinum toxin	Spasmodic (dystonia)	Effective, well-tolerated	8, 9, 10
Treat underlying	Infectious, inflammatory	Antibiotics, abscess drainage	6, 1

Table 4: Main Treatment Options

Physical Therapy and Conservative Management

• First-line for Congenital Muscular Torticollis: Early, structured physical therapy focusing on gentle stretching of the SCM and neck muscles is highly effective in infants and young children 1, 4, 11.
• Education: Parents are taught positioning and stretching exercises to perform at home 11.
• TCM Massage: Traditional Chinese Medicine massage has shown similar efficacy to stretching therapy in infants and children 12.

Medical and Surgical Interventions

• Botulinum Toxin Injections: For spasmodic torticollis (cervical dystonia), botulinum toxin (type A) injections into overactive muscles are effective and generally well-tolerated. These reduce abnormal muscle contractions and pain 8, 9, 10.
• Surgical Release or Denervation: Reserved for severe, refractory cases where conservative measures fail, or structural anomalies are present. Procedures may include SCM release (for congenital cases) or selective peripheral denervation (for intractable dystonia) 1, 8.

Treating Underlying Causes

• Infectious/Inflammatory Causes: Require targeted therapy such as antibiotics for infections or surgical drainage of abscesses 6, 1.
• Neurological or Ocular Causes: Management is directed at the underlying disorder, which may involve neurology, ophthalmology, or psychiatry 1, 7.

Long-Term Management and Follow-up

• Monitoring for Complications: Children with persistent or severe torticollis should have regular follow-up to screen for musculoskeletal, developmental, or visual issues 4, 11.
• Multidisciplinary Approach: Complex cases may require input from pediatricians, neurologists, orthopedic surgeons, physiotherapists, and other specialists.

Conclusion

Torticollis is a complex clinical condition with diverse presentations, underlying causes, and management pathways. Early recognition and tailored intervention are key to optimal patient outcomes. Here’s a summary of the main points discussed:

• Symptoms: Characterized by head tilt, chin rotation, limited neck movement, and possible pain.
• Types: Includes congenital muscular, acquired, spasmodic (cervical dystonia), and ocular forms.
• Causes: Range from muscular contractures and trauma to infections, neurological diseases, and psychiatric factors.
• Treatment: Relies on early physical therapy for congenital cases, botulinum toxin for dystonia, surgery for refractory cases, and management of underlying causes for acquired forms.

Understanding the nuances of torticollis ensures that patients—especially infants and children—receive prompt, effective care, and are protected from long-term complications.