Congenital muscular torticollis and the associated craniofacial changes

Physical Therapy Management of Congenital Muscular Torticollis: A 2024 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association Academy of Pediatric Physical Therapy

BACKGROUND

Congenital muscular torticollis (CMT) is a postural condition evident shortly after birth. The 2013 CMT Clinical Practice Guideline (2013 CMT CPG) set standards for the identification, referral, and physical therapy management of infants with CMT, and its implementation resulted in improved clinical outcomes. It was updated in 2018 to reflect current evidence and 7 resources were developed to support implementation. Purpose: This 2024 CMT CPG is intended as a reference document to guide physical therapists, families, health care professionals, educators, and researchers to improve clinical outcomes and health services for children with CMT, as well as to inform the need for continued research. Results/Conclusions: The 2024 CMT CPG addresses: education for prevention, screening, examination and evaluation including recommended outcome measures, consultation with and referral to other health care providers, classification and prognosis, first-choice and evidence-informed supplemental interventions, discontinuation from direct intervention, reassessment and discharge, implementation and compliance recommendations, and research recommendations.

Clinical Application of Custom Neck Collar with Negative Sensory Feedback in Children with Intractable Torticollis

BACKGROUND/OBJECTIVES

The aim of this study was to investigate the effect of a custom neck collar with negative sensory feedback for the treatment of torticollis that was previously unresponsive to conservative or surgical treatment.

METHODS

Twenty-four children diagnosed with unresponsive or intractable torticollis were enrolled in this two-stage, single-arm study. The ipsilateral aspect of the orthosis is adjustable in height and designed to provide support between the clavicle and the mandibular angle on the tilted side. In stage 1 (the adjustment period), the orthosis with a smooth surface was applied for 2 h per day for 3 months. In stage 2, a rough surface with a hook-and-loop fastener (Velcro©) was attached to the collar, and it was worn for a further 2 h a day for 3 months. Twenty children (mean age 63.95 ± 13.44 months) were included in the analysis.

RESULTS

The mean torticollis angle was 17.60 ± 5.65° (mean ± SD) at baseline; 14.15 ± 3.62° directly after stage 1; and 6.00 ± 3.67° directly after stage 2 (X2 = 36.685, df = 19, p = 0.000).

CONCLUSIONS

This study demonstrated the feasibility, therapeutic effect, and safety of a novel tactile feedback orthosis for the treatment of children with torticollis. The use of a custom neck collar with negative sensory feedback may be a viable therapeutic option for the treatment of unresolved or intractable torticollis.

Myomodulation Using Botulinum Toxin in Septorhinoplasty for Crooked Noses: Introducing the Concept and Application of Nasal Muscle Imbalance Theory

The role of septorhinoplasty for adequate correction of deviated nose is well documented, but the rationales and patterns for recurrences after proper rhinoplasty remain unclear. There has also been little attention given to the influence of nasal musculatures on the stability of nasal structures after septorhinoplasty. The aim of this article is to propose our nasal muscle imbalance theory, which may explain the potential reason for redeviation of the noses in the initial period after septorhinoplasty. We postulate that in a chronically deviated nose, the nasal muscles on the convex side will be stretched and develop hypertrophy after prolonged period of increased contractile activity. On the contrary, the nasal muscles on the concave side will undergo atrophy due to reduced load requirement. In the initial period of recovery after a septorhinoplasty to bring the nose back to midline, this muscle imbalance is still uncorrected with unequal pulling forces on the nasal structure because the stronger nasal muscles on the previously convex side is still hypertrophied and exert stronger forces compared with the previously concave side, therefore increasing the risk of redeviation of the nose back to the preoperative side until muscle atrophy occurs in the convex side and a balanced nasal muscle pull is achieved. We believe that postseptorhinoplasty botulinum toxin injections can be used as an adjunct in rhinoplasty surgery to effectively block the pulling actions of the stronger or overacting nasal muscles by speeding up the atrophy process while allowing patient's nose to heal and stabilize in the desired position. However, further studies to objectively confirm this hypothesis is required, which include comparing topographic measurements, imaging and electromyography signals before and after injections in postseptorhinoplasty patients. The authors have already planned a multicenter study to further evaluate this theory.

Effectiveness of the Treatment of Physiotherapy in the Congenital Muscular Torticollis: A Systematic Review

A single congenital muscular torticollis (CMT) is a postural musculoskeletal deformity and is characterized by the shortening or stiffness of the sternocleidomastoid muscle. The reported incidence of CMT ranges from 0.2% to 2%. The objective is to evaluate the effect of physical therapy programs on CMT. For the search, PubMed, Scopus, Web of Science, PEDro and Cochrane databases were used. Randomized controlled trials published between 2018 and 2023 have been included. This study follows the PRISMA 2020 statement and has been registered in the PROSPERO database. Finally, six studies were included. The cervical range of motion (ROM) in rotation was the most analyzed variable, followed by the ultrasound evaluation; one of the studies included the analysis of children's motor development with the Alberta scale. All research found benefits associated with soft tissue mobilization, passive stretching techniques and manual therapy of the cervical spine. In conclusion, it is possible to recommend manual therapy and passive stretching techniques for the treatment of CMT, with significant results on the cervical ROM.

Surgical Treatment of Congenital Muscular Torticollis: Significant Improvement in Health-related Quality of Life Among a 2-year Follow-up Cohort of Children, Adolescents, and Young Adults

OBJECTIVE

Surgical treatment of congenital muscular torticollis (CMT) has been proven clinically effective in cases that fail to normalize after conservative treatment, but reports on self-reported outcome and quality of life have been scarce. This study aimed to assess health-related quality of life (HRQoL) in children, adolescents, and young adults undergoing surgical treatment for CMT, comparing HRQoL with clinical outcomes.

METHODS

We conducted a level 2 prospective observational study on a surgically treated CMT cohort at a single tertiary center. The surgeries focused on releasing all tightness, and the medial head was routinely elongated to preserve cosmetic function. Patients underwent rigorous pre/postoperative assessments and follow-up. A strict postoperative protocol entailing stretching, physiotherapy, and positional exercises was adhered to for a minimum of 6 months. The Cheng and Tang torticollis scoring system and PedsQLTM 4.0 generic core scales were used to evaluate clinical outcome and HRQoL, respectively.

RESULTS

The study included 31 patients, averaging 11.4 years. Significant improvements in range of motion, deformities, and overall subjective satisfaction were observed 2 years postoperatively. The Cheng and Tang score improved overall significantly from fair (9.9 points) to excellent (17.9 points) after 2 years ( P <0.001). The oldest patients showed less improvement than the youngest ones, especially regarding craniofacial asymmetry ( P =0.004). Patient PedsQL scores significantly improved 2 years post-surgery ( P =0.040), with no discernable age differences.

CONCLUSION

Our findings demonstrated significant improvements in both HRQoL and clinical outcomes after surgical treatment of CMT. The PedsQL score seemed sensitive to the clinical changes.

Combined effect of external treatment of herbal medicine and tuina in congenital muscular torticollis: Systematic review and meta-analysis

BACKGROUND

Congenital muscular torticollis (CMT) is the third most common musculoskeletal disease in children. With no standardized treatment method hence, so it is necessary to find an effective treatment method that can be received comfortably by children. This review assessed the efficacy of an external treatment of herbal medicine (ETHM) with tuina for CMT in children.

METHODS

This study searched the English, Chinese, and Korean databases (total of 10) until June 7 2022, without any language restrictions. All included studies were randomized clinical trials (RCTs) of ETHM with tuina as an intervention comparted to the same tuina alone according to the inclusion and exclusion criteria. The mean differences (MD), standardized mean differences (SMD), risk ratio (RR) with the 95% confidence interval (CI), and risk of bias (ROBs) were calculated using Review Manager Version 5.4 software. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) rating system was used to assess the quality of evidence. The publication bias was evaluated using a funnel plot, the Egger test, the fail-safe N test, and the Duval and Tweedle's trim and fill method using Review Manager Version 5.4 software, the software R Version 4.1.1 and R studio Version 1.4.1106 program.

RESULTS

Nineteen RCTs with 1710 patients were included in the meta-analysis. ETHM plus tuina improved the outcomes of the total effective rate (TER) [RR 1.21, 95% CI:1.15 to 1.26, P < .001], sternocleidomastoid (SCM) muscle thickness [MD: -1.82, 95% CI: -2.23 to -1.41, P < .001], cervical rotation range [MD: 13.43, 95% CI: 10.41-16.45, P < .001] and lateral flexion range [MD: 8.50, 95% CI: 6.15-10.85, P < .001], tissue elasticity grade [SMD: -0.46; 95% CI: -0.71 to -0.22, P = .0002], muscle elasticity scores [RR: 1.56; 95% CI: 1.04 to 2.34, P = .03], and clinical symptom and sign scores [SMD: -0.78; 95% CI: -1.09 to -0.47, P < .001].

CONCLUSIONS

ETHM plus tuina have a combined effect on CMT children. However, further studies with high-quality clinical trials are needed to obtain more robust clinical evidence.

A rare case of 9 years congenital muscular torticollis treated with complete unipolar sternocleidomastoid release: A case report and literature review

INTRODUCTION

Congenital muscular torticollis (CMT), when left untreated, may result in numerous complications such as eye movement disorder, craniofacial asymmetry, neck pain and compensatory asymmetrical spine curvature that worsens with age. We reported a 9-year-old boy with neglected CMT treated with complete unipolar sternocleidomastoid release.

PRESENTATION OF CASE

A 9-year-old boy presented with his head tilted to the left since he was born. Physical examination revealed tense and uptight sternocleidomastoid muscle. The patient then underwent complete unipolar stenocleidomastoid release. Postoperatively, the patient completed 3 months of aggressive physical therapy thrice a week followed by a home exercise regimen once the patient was discharged from therapy. At six months of follow-up, the active range of motion of his neck was markedly improved in all directions, and his cervical spine was noted to be straight. The CMA was also decreased from 14 to 0 degree.

DISCUSSION

It is recommended that, in those with CMT, the surgery should be performed between 1 and 4 years of age. However, in our case, the patient was already 9 years old. Nevertheless, he had achieved regained full cervical range of motion, and significant improvement of CMA angle (from 14 to 0 degree postoperatively) after undergoing unipolar sternocleidomastoid release and three months of aggressive physical therapy.

CONCLUSION

Surgical intervention followed by aggressive physical therapy for patients with neglected CMT, despite late presentation, may still carry a favourable outcome.

Is Longstanding Congenital Muscular Torticollis Provoking Pelvic Malalignment Syndrome?

It has been reported that congenital muscular torticollis (CMT) may result in secondary scoliosis over long-term follow-ups. However, there are few reports on whether CMT causes pelvic malalignment syndrome (PMS). This study aimed to investigate the relationship between CMT and PMS and to determine the factors associated with the development of PMS in children with longstanding CMT. Medical records of 130 children with CMT who had long-term follow-up were reviewed retrospectively. The chi-squared test and logistic regression analysis were used to determine which initial clinical parameters contributed to the development of PMS. Among 130 children with CMT, 51 (39.2%) developed PMS with or without compensatory scoliosis during long-term follow-up, indicating a high prevalence of PMS in children with a CMT history. Initial clinical symptoms such as a limited range of motion of the neck or the presence of a neck mass could not predict the development of PMS. Even if the clinical symptoms are mild, long-term follow-up of children with CMT is essential to screen for PMS.

A Quantitative Analysis of Facial Asymmetry in Torticollis Using 3-Dimensional Photogrammetry

OBJECTIVE

To assess whether children with torticollis have quantifiably greater facial asymmetry than their age-matched controls using 3-dimensional (3D) photogrammetry.

DESIGN

We retrospectively analyzed patients diagnosed with torticollis and age-matched volunteers who underwent 3D photogrammetry of their faces. We calculated the root mean square deviation (RMSD) between native and reflected facial images, as a measure of asymmetry. Two observers independently measured RMSD values for all study participants. The Spearman correlation coefficient evaluated interobserver reliability. The Wilcoxon rank-sum test with Bonferroni adjusted P values for multiple comparisons.

SETTING

Institutional.

PARTICIPANTS

Twenty patients diagnosed with torticollis and 12 age-matched volunteers. Patients were analyzed on a computer database and volunteers were selected and consented in the hospital. We excluded patients with a history of facial trauma, facial operations, or other craniofacial diagnoses.

INTERVENTIONS

Facial surface scans were obtained using the Canfield Vectra stereophotogrammetry system. The technology captures surface anatomy without radiation.

MAIN OUTCOME MEASURES

RMSD comparisons between patients with torticollis and age-matched controls.

RESULTS

Compared to controls, patients with torticollis had statistically significant greater full face, upper third, and middle third facial asymmetry. There was a trend toward greater asymmetry of the lower facial third.

CONCLUSIONS

We used 3D photogrammetry to quantitate facial asymmetry from torticollis. We found greater asymmetry in patients with torticollis than in their unaffected peers. All areas of the face appeared to be affected, though the asymmetry in the lower facial third just failed to reach significance.

Experiences of Parents of Infants Diagnosed With Mild or Severe Grades of Congenital Muscular Torticollis

PURPOSE

The primary purpose of this study was to describe the experiences of parents of infants diagnosed with congenital muscular torticollis (CMT). A secondary purpose was to compare the experiences of parents of infants with mild grades versus severe grades of involvement based on the CMT severity classification system.

METHODS

Through semistructured interviews, a qualitative phenomenological approach of inquiry was used to investigate the lived experiences of 12 parents.

RESULTS

Eight themes common to both groups of parents were identified. Findings indicated having an infant with CMT has a significant effect on the parents and other caregivers. Two themes were unique to parents of the infants with severe CMT.

CONCLUSIONS

Parents are faced with a diagnosis that requires regular therapy visits and a challenging home program. A multimodal approach by clinicians for teaching and supporting parents during the episode of care may best address their unique challenges and stresses.

Rigging the nose: a pilot study using barbed sutures in patients with deviated nose

Background

A deviated nose is a very common developmental feature in Caucasian populations and represents a frequent indication for rhinoplasty, either functional or esthetic. We aim to assess the pattern of nasal axis stabilization after rhinoplasty in the deviated nose on the basis of anthropometric measurements: median face axis (MFA), interpupillary meridian axis (IMA), and scoliosis angle (SA); to study possible effects of rigging the nose in the midfacial soft tissues using absorbable soft sutures; to investigate possible side effects.

Methods

Seventy patients with a non-traumatic deviated nose (n = 50 as control group, n = 20 as treated group with placement of barbed suture in the midfacial soft tissues) underwent rhinoplasty procedures. We retrospectively examined the pattern of deviation recurrence over time in a consecutive series of 70 non-traumatic patients undergoing primary esthetic or functional rhinoplasty (n = 50 as control group, n = 20 as treated group with placement of barbed suture in the midfacial soft tissues). Patients were followed up at 1 week, 2 weeks, 1 month, 3 months, and 1 year postoperatively.

Results

Ninety-three percent (65/70) of the patients had an asymmetric face after comparing the two anthropometric angles MFA and IMA. Overcorrection of NA at one week postoperatively was observed in 1.25% and 35.7% of patients in the control and treated groups, respectively (p = 0.006). MFA shifted from 4.16° ± 3.1° preoperatively to 1.2° ± 1.4° at 1 week, 1.0° ± 1.1° at 2 weeks, 1.1° ± 1.4° at 1 month, 1.1° ± 1.5° at 3 months, and 1.7° ± 2° at 1 year in the control group. In the treated group, MFA shifted from 5.7° ± 2.9 preoperatively to − 0.34° ± 2.9° at 1 week, 1.0° ± 1.1° at 2 weeks, 0.59° ± 0.96° at 1 month, 1.22° ± 0.83° at 3 months, and 1.63° ± 0.8° at 1 year. Differences between the groups were significant at 1 week (p = 0.02), but differences were not significant at 2 weeks, 1 month, 3 months, and 1 year.

Conclusions

This pilot study demonstrates that the progressive re-deviation pattern is altered during the first weeks after surgery in the barbed sutures group. Absorbable barbed sutures in facial soft tissues are well tolerated. Longer lasting sutures may help to obtain definite advantage.

Level of evidence: Level IV, therapeutic study.

The Transaxillary Subcutaneous Endoscopic Sternocleidomastoid Muscle Division as an Approach for the Surgical Treatment of Congenital Muscular Torticollis in Children

Traditionally congenital muscular torticollis is treated with a neck incision which results in a neck scar. The purpose of this study was to evaluate the effectiveness of the transaxillary subcutaneous endoscopic sternocleidomastoid muscle division for the treatment of congenital muscular torticollis. This is a prospective study of 7 children with torticollis treated surgically by the transaxillary endoscopic approach in the department of Pediatric Surgery between 2014 and 2018. The age at operation ranged from 5.5 to 9 years, mean 7.3 (SD ± 1.3) years. The mean operation time was 65 min. The complete muscular release was successfully completed using the endoscopic approach. There were no major complications. All patients improved in gaze angle, lateral tilt and range of motion. There was no cosmetically unacceptable scar visible at the surgical sites in all patients during follow up. All families were pleased with the cosmetic outcome. The transaxillary subcutaneous endoscopic technique can be applied as a surgical approach for children with muscular torticollis an alternative to traditional open methods. It is a technically feasible procedure in children, provides excellent cosmesis and moreover avoids scarring on the neck.

Body Weight at Birth: The Only Risk Factor Associated with Contralateral Clavicular Fracture in Patients with Congenital Muscular Torticollis

To date and to the best of our knowledge, there have been limited studies on the risk factor of clavicle fracture combined with congenital muscular torticollis (CMT), despite it being the most common fracture in newborns. So, the aim of this study was to investigate the risk factors associated with clavicular fracture combined with CMT, and its effect on prognosis. In this study, a total of 134 infants with CMT were included. The risk factors associated with clavicular fracture combined with CMT were analyzed. To analyze the correlation between the clinical parameters and the clavicular fracture in patients with CMT, demographic data, such as body weight at birth, maternal age, gender, gestational age, delivery method, sternocleidomastoid (SCM) thickness of ipsilateral side, its ratio between the ipsilateral and contralateral side, and the first visitation date after birth were evaluated. In the results of this study, the clavicular fracture was found in 15 of 134 patients with CMT (19%). In multivariate logistic analysis, the body weight at birth was the only significant parameter for predicting clavicular fracture in patients with CMT (p-value < 0.05). However, there was no significant difference of treatment duration between CMT infants with or without clavicular fracture. In infants with CMT, the area under the ROC curve of the body weight at birth for predicting clavicular fracture was 0.659 (95% CI, 0.564–0.745.; p < 0.05). The optimal cut-off value obtained from the maximum Youden index J was 3470 g (sensitivity: 57.14%, specificity: 75.76%), and the odd ratio of clavicular fracture in patients with CMT increased by 1.244 times for every 100 g of body weight at birth. In conclusion, birth weight appears to be a clinical predictor of clavicular fracture in infants with CMT. More studies and discussions are needed on whether any screening should be recommended for detecting the concurrent clavicular fracture in subjects with CMT.

Congenital muscular torticollis - a proposal for treatment and physiotherapy

Congenital muscular torticollis (CMT) is a condition manifested by unilateral thickening and/or shortening of the sternocleidomastoid muscle. It can lead to local or global consequences (i.e., forced position and limitation of mobility of the cervical spine and head, delay of motor development). Early recognition of CMT symptoms and the implementation of conservative treatment, considered effective in the majority of cases, are an important part of physical therapy in CMT. The aim of the study is to review literature presenting the methods of physical therapy in CMT and to create the authors’ own proposals for treatment, based on the results of this review. Based on subject-matter literature and our own experience, algorithms for the rehabilitation procedure have been proposed, presenting the general scheme of action in CMT and management depending on the clinical form and age of the child in whom therapy was started (up to 5 months and after 6 months). The authors’ proposed algorithm did not strictly specify the frequency of sessions with a physiotherapist, because this is the resultant of many factors. The main ones include the child's age on the day of initiation of therapy, the clinical form of torticollis, the presence of muscle tone disorders and/or skull asymmetry, but also, the correctness of performing exercises proposed as part of the home-based programme, regularity of therapy and compliance with postural programme principles.

Ipsilateral Hypertrophy of the Mastoid Process in Surgical Cases of Congenital Muscular Torticollis

OBJECTIVE

This study was to investigate ipsilateral hypertrophy of the mastoid process in the patients with congenital muscular torticollis (CMT).

DESIGN

Retrospective cross-sectional study.

PATIENTS

Children with CMT.

METHODS

A total of 212 surgical cases of patients with CMT (age: 50.9 ± 44.3 months) and 212 age- and gender-matched controls (age: 50.4 ± 44.2 months) were included. The mastoid process volume was calculated and compared for both groups on the computed tomography axial images. A linear regression analysis was performed between the age and the intrasubject volume difference in the mastoid process.

RESULTS

The volume of the mastoid process in the CMT side was significantly larger than that of the non-CMT side in the CMT group (32.2 ± 30.3 cm³ vs 21.9 ± 22.8 cm³; P < .001). In the control group, there was no significant difference between the volume of the right and left mastoid process (21.6 ± 24.6 cm³ vs 21.2 ± 23.8 cm³; P = .472). The intrasubject volume difference in the mastoid process in the CMT group showed a linear increase with the age (adjusted R ² = 0.286; P < .001), and the volumetric asymmetry of the mastoid process became more severe over age compared to the control group.

CONCLUSION

We showed ipsilateral hypertrophy of the mastoid process in patients with CMT and demonstrated that the volumetric asymmetry increased with age.

Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy

BACKGROUND

Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified.

PURPOSE

This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice.

RESULTS/CONCLUSIONS

The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.

A randomized controlled study on the efficiency of soft tissue mobilization in babies with congenital muscular torticollis

BACKROUND

Soft tissue mobilization techniques (STM) are used in clinical practice in treatment of congenital muscular torticollis(CMT).However, little is known about its effectiveness.

OBJECTIVES

To investigate whether using STM to manage CMT in babies with mild to moderate head tilt was effective or not.

METHODS

Twenty-nine babies with CMT aged between 0-6 months, who had a head tilt from 5 to 20 degrees were allocated to two groups. Both groups received a baseline home program (positioning, handling strategies, stretching and strengthening exercises, environmental adaptations). The study group (SG) also received STM three times a week. Babies were evaluated initially, at six weeks, at 12 weeks and for follow-up at 18 weeks with muscle function scale, head tilt and range of motion for neck lateral flexion and rotation.

RESULTS

Both groups showed significant improvements in all measured parameters (p< 0.05). In comparison of groups, there were differences at six weeks in favor of the SG for neck rotation (0.001) and head tilt (= 0.006); but at 12 weeks and follow up, there were no longer any differences between the groups in any of the measured parameters.

CONCLUSIONS

STM techniques are effective in getting faster positive results in the treatment of CMT.

Interrater and Intrarater Reliability of the Congenital Muscular Torticollis Severity Classification System

PURPOSE

To establish inter- and intrarater reliability for determining severity grades of the congenital muscular torticollis severity classification system (CMT-SCS).

METHODS

A prospective reliability study with 145 physical therapists recorded severity ratings on 24 randomly-ordered patient cases including age of infant, cervical range of motion, and presence or absence of sternocleidomastoid mass. To compute intrarater reliability, cases were randomly reordered and graded by 82 of the original raters.

RESULTS

For the CMT-SCS, overall reliability was good with an interrater reliability intraclass correlation coefficient (ICC) (2,1) of 0.83 (95% confidence interval [CI], 0.74-0.91) and an intrarater reliability ICC (3,1) of 0.81 (95% CI, 0.66-0.91).

CONCLUSIONS

The CMT-SCS has good reliability for infants up to 12 months of age. Physical therapists can use the scale for initial assessment of infants suspected to have CMT. The CMT-SCS should be standard documentation for infants with CMT.

Craniovertebral Junction Abnormalities in Surgical Patients With Congenital Muscular Torticollis

Our clinical experience led us to realize that craniovertebral junction (CVJ) abnormalities were common in surgical patients with congenital muscular torticollis (CMT). This study aimed to report the concurrence rate of CVJ abnormalities in surgical patients with CMT, along with comprehensive evaluation of type of concurrent CVJ abnormalities. This was a retrospective cohort study in a tertiary hospital, including 41 subjects who underwent surgical release for CMT at the mean age of 8.38 years. The presence of CVJ abnormalities was analyzed, using craniofacial 3-dimensional computed tomography images. The concurrence rate of CVJ abnormalities was 70% in surgical patients with CMT. Subjects with CVJ abnormalities had, on average, 1.48 abnormalities. The CVJ abnormalities were rotation and lateral shift of the atlanto-axial joint along with rotation of atlanto-occipital joint, where rotation of the atlanto-axial joint was most common (82.76%). There is no patient with anterior shift of the atlanto-axial joint. Chronic mechanical tension by the contracted unilateral sternocleidomastoid muscle of CMT could be responsible for concurrent CVJ abnormalities. The CVJ abnormalities are more common in the atlanto-axial joint than in the atlanto-occipital joint. In conclusions, CVJ abnormality seems to be a common concurrent skeletal complication of CMT, at least, in surgical patients. The CVJ abnormality might be included in the list of skeletal complications of CMT. If CVJ abnormalities are significantly more common in surgical patients with CMT, CVJ abnormalities might be one of predictors of surgical patients with CMT.

Surgical management of congenital torticollis in children older than 7 years with an average 10-year follow-up

The aim of the present study is to present the results of the surgical management of late presenting cases of congenital muscular torticollis. Between 1990 and 2010, 31 cases of late presenting congenital muscular torticollis were managed surgically in our department. Postoperatively, head halter traction was applied for 10 days; a cervical brace was applied for 5 weeks, followed by a soft one collar for 3 months. The final result was assessed on the basis of the criteria of Cheng and Tang. In total, 84% of patients achieved an excellent final result and 16% of the patients achieved a good result. Our results indicated that in children older than 7 years, surgical release combined with appropriate orthosis and a structured physiotherapy regime can lead to satisfactory results.

Do obstetric risk factors truly influence the etiopathogenesis of congenital muscular torticollis?

Background

Congenital muscular torticollis (CMT) is seen in childhood and presents within months after birth. The etiology remains unknown; however, medical textbooks suggest trauma at birth as a main reason. The aim of this study was to systematically describe obstetric and perinatal outcomes in a population of children with a confirmed congenital muscular torticollis diagnosis.

Materials and methods

Children with a validated diagnosis of congenital muscular torticollis born at Aarhus University Hospital from 2000 to 2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristics were obtained from databases and from medical records, and systematically described.

Results

In this study, there were no differences in birth characteristics in children with left- and right-sided torticollis, between boys and girls or between the conservatively treated and the children who needed surgery. Most of the children with congenital muscular torticollis in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.

Conclusions

The results of the present study suggests that complicated birth or birth trauma may not be the main cause of congenital muscular torticollis and point towards intrauterine and prenatal reasons for its development.

Level of evidence according to OCEBM levels of evidence working group

3

Functional and Aesthetic Recovery of Congenital Muscular Torticollis with Intramuscular Stromal Vascular Fraction Enriched Fat Grafting

Congenital muscular torticollis is a well-known pathological condition caused by the contracture and shortening of the sternocleidomastoid muscle. This condition is manifested by a neck postural deformity often accompanied by some kind of facial asymmetry. Once diagnosed, treatment by early physiotherapy is generally successful in a high percentage of patients if performed during the first year of life. Later, especially after the fourth year, conservative treatment is usually far less effective, and surgical techniques remain the only way to improve neck contour and function. The author reports two cases of adult patients affected by this condition and successfully treated with a novel therapeutic approach consisting of percutaneous myotomies and intramuscular cell-assisted fat grafting.

Two cases of adult patients diagnosed with congenital muscular torticollis were analyzed after treatment with percutaneous myotomies and intramuscular fat grafting. The first patient had a history of unsuccessful treatment in infancy with bipolar release of the sternocleidomastoid muscle and was treated with two sessions of fat grafting. The second patient had a history of neglected torticollis and was treated with a single session of cell-assisted fat grafting. In both cases, facial asymmetries were simultaneously treated with the same fat grafting protocol used to treat the muscle. Improvements in muscle function and in face and neck contours were extremely good and stable in both patients. The postoperative course for both patients was uneventful and with a very short and easy recovery when compared with the techniques described to date.

Neglected congenital muscular torticollis in adults, or in patients who have not responded adequately to surgical treatment, has been treated safely with percutaneous myotomies and intramuscular fat grafting. The benefit is a scarless technique that provides simultaneous recovery of neck aesthetics and muscle function together with a very short recovery time. Further studies must be conducted to properly evaluate the long-term safety and convenience of cell enrichment to achieve better and long-lasting results.

Congenital muscular torticollis: Use of gaze angle and translational deformity in assessment of facial asymmetry

BACKGROUND

Assessment of facial asymmetry is challenging in torticollis deformity. Neck tilt in toroticollis is associated with deviation of horizontal ocular gaze and translation of neck from the midline. These deviations can be assessed clinically and can be used as surrogate marker for facial asymmetry.

MATERIALS AND METHODS

Thirty five children with congenital muscular torticollis (CMT) were classified into three grades of severity based on the new clinical score. The parameters included in the scoring system included rotational deficit, side flexion deficit, gaze angle (GA), and translational deformity (TD). Seven children had Grade I (mild), 18 had Grade II (moderate), and 10 had Grade III (severe) CMT. There were 21 girls and 14 boys with a mean age of 8.46 years (range 3-16 years). Twenty two children underwent a bipolar release, and 13 had unipolar surgery. Facial asymmetry (FA) signs were noted and based on GA and TD; all children had a deviation from the neutral angles (GA of 90° and 0 mm translation from the midsterna plumb line were considered neutral angle). The final outcome was based on the modified Cheng and Tang Score.

RESULTS

The mean GA in Grade I, II, and III improved from 81.71 to 90, 72.77 to 89.16, and 66.60 to 88, respectively (Chi-square P < 0.0001). The TD improved from 15 mm to 0 mm, 25.83 mm to 3.05 mm, and 36.6 mm to 6 mm in Grade I, II, and III, respectively (Chi-square P < 0.05). The rotational and side flexion deficits also improved across all grades of severity but were not statistically significant (P < 0.911 and P < 0.04). Twenty four children had an excellent outcome with complete correction of their GA and TD. Four children with Grade II CMT and seven children with Grade III who had a residual translation of 5 mm or more and GA less than neutral horizontal had a good outcome. No child had problems with scar cosmesis or prominent lateral bands, and there was no recurrence of deformity at a mean followup of 28 months (range 24-32 months).

CONCLUSION

The GA and TD can be used to assess FA in torticollis management and significant improvement can be expected even in severe cases.

Change of Facial Asymmetry in Patients With Congenital Muscular Torticollis After Surgical Release

BACKGROUND

A number of studies have shown that facial asymmetry improves in congenital muscular torticollis (CMT) patients after surgical release. This study confirmed the improvement in facial asymmetry, and analyzed factors that affect the change of facial asymmetry in CMT patients after surgical release by using objective and quantitative methods.

METHODS

Facial asymmetry was analyzed in 60 CMT patients who underwent surgical release before 10 years of age. Horizontal and lower facial asymmetry angles (HFAA and LFAA) in the clinical photograph were used to measure facial asymmetry. Postoperative improvements in HFAA and LFAA were evaluated in each age group, after grouping the patients by age. Patients were divided into 2 groups according to the postoperative head tilt and functional deficit. Postoperative improvements in HFAA and LFAA were compared between 2 groups. The relationships between postoperative improvements in HFAA and LFAA and independent variables (age, follow-up period, preoperative HFAA or LFAA, postoperative head tilt, and postoperative functional deficit) were analyzed.

RESULTS

Mean age at operation was 34.8 months (range, 6-120 mo). Horizontal facial asymmetry angle was improved significantly postoperatively in groups <5 years of age. Lower facial asymmetry angle was improved significantly postoperatively in all age groups. No significant difference was found in the postoperative improvements in HFAA and LFAA between 2 groups according to the postoperative head tilt and functional deficit. In the correlation analysis, postoperative improvements in HFAA and LFAA were proportional to the follow-up period (r = 0.256, P = 0.048) and preoperative HFAA or LFAA (r = 0.600, P < 0.001).

CONCLUSIONS

Facial asymmetry in CMT patients can be improved in part if surgical release is performed before 10 years of age and the possibility of improvement may be different according to the area of the face. After surgical release, facial asymmetry will improve over a long period of time, and patients with more severe facial asymmetry have a better remodeling potential to achieve facial symmetry.

Effectiveness of Surgical Release in Patients With Neglected Congenital Muscular Torticollis According to Age at the Time of Surgery

Objective

To identify the correlation between change in spinal deformities after surgical release and age at the time of surgery, and the effectiveness of surgical release in patients with neglected congenital muscular torticollis (CMT).

Methods

This was a retrospective study of 46 subjects with neglected CMT who had undergone surgical release at age ≥5 years at a tertiary medical center between January 2009 and January 2014. Spinal deformities were measured on anteroposterior plain radiographs of the cervical and whole spine, both preoperatively and postoperatively, to assess 3 parameters: cervicomandibular angle (CMA), lateral shift (LS), and Cobb angle (CA). We analyzed the change in spinal deformities after surgical release in consideration of age at the time of surgery.

Results

The median age at the time of surgery was 12.87 years. All 3 parameters showed significant improvement after surgical release (median values, pre- to post-surgery: CMA, 12.13° to 4.02°; LS, 18.13 mm to 13.55 mm; CA, 6.10° to 4.80°; all p<0.05). There was no significant correlation between age at the time of surgery and change in CMA (R=0.145, p=0.341) and LS (R=0.103, p=0.608). However, CA showed significant improvement with increasing age (R=0.150, p=0.046).

Conclusion

We assessed the correlation between change in spinal deformities after surgical release and age at the time of surgery. We found that that surgical release is effective for spinal deformities, even in older patients. These findings enhance our understanding of the effectiveness and timing of surgical release in patients with neglected CMT.

Facial asymmetry in ocular torticollis

Torticollis can arise from nonocular (usually musculoskeletal) and ocular conditions. Some facial asymmetries are correlated with a history of early onset ocular torticollis supported by the presence of torticollis on reviewing childhood photographs. When present in an adult, this type of facial asymmetry with an origin of ocular torticollis should help to confirm the chronicity of the defect and prevent unnecessary neurologic evaluation in patients with an uncertain history. Assessment of facial asymmetry consists of a patient history, physical examination, and medical imaging. Medical imaging and facial morphometry are helpful for objective diagnosis and measurement of the facial asymmetry, as well as for treatment planning. The facial asymmetry in congenital superior oblique palsy is typically manifested by midfacial hemihypoplasia on the side opposite the palsied muscle, with deviation of the nose and mouth toward the hypoplastic side. Correcting torticollis through strabismus surgery before a critical developmental age may prevent the development of irreversible facial asymmetry. Mild facial asymmetry associated with congenital torticollis has been reported to resolve with continued growth after early surgery, but if asymmetry is severe or is not treated in the appropriate time, it might remain even with continued growth after surgery.

Effectiveness of Surgical Treatment for Neglected Congenital Muscular Torticollis: A Systematic Review and Meta-Analysis

BACKGROUND

Findings on the effectiveness of surgical release for neglected congenital muscular torticollis have been conflicting. This systematic review aims to examine the literature describing the effectiveness of surgery for neglected congenital muscular torticollis.

METHODS

The authors conducted a systematic review to examine the effectiveness of surgical treatment for neglected congenital muscular torticollis by means of meta-analysis. The authors searched MEDLINE, EMBASE, the Cochrane library, and KoreaMed for all articles published before May of 2014. Studies with quantitative data describing the effectiveness of surgery for congenital muscular torticollis were included. The primary outcomes after surgery were (1) clinical outcome measured by scoring systems; (2) change in range of motion of the neck; and (3) change in skeletal deformities, measured by Cobb angle and the cervicomandibular angle. Effect estimates were pooled using a random-effects meta-analysis.

RESULTS

Twelve studies were included in the review (published between 1976 and 2014), including a total of 220 patients with neglected congenital muscular torticollis. All studies used an interrupted time-series design. Surgical treatment was successful in 81 percent of cases, based on the scoring systems for surgical outcome. Outcomes of surgery performed in patients older than 15 years did not differ significantly from those of surgery performed in patients aged 15 years or younger. The range of motion of the neck and skeletal deformities showed significant improvement after surgery.

CONCLUSIONS

Surgical treatment for neglected congenital muscular torticollis produced satisfactorily successful results, with improvement in both the range of motion of the neck and secondary skeletal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Improvement of Congenital Muscular Torticollis with Mild Symptoms in Non-Treated Adult after Simple Surgical Myotomy of Sternocleidomastoid Muscle under Local Anesthesia

In adult congenital muscular torticollis (CMT) patients, physical therapy is not as effective because the development of sternocleidomastoid muscle (SCM) muscle is complete. While surgical release can address CMT in adult patients, the risk of general anesthesia and visible postoperative scar is a concern, expecially in patients with mild symptoms. In this paper, we report our experience in treating such patients with minimal-incision myotomy under local anesthesia. A review was performed for all adult patients who had undergone the simple myotomy procedure. Surgical indication was reserved for patients with mild fibrotic band in the SCM muscle with minimal lengthdiscrepancybetween the muscles. All patients had recognizable head tiltand palpation of fibrotic band on affected side of the neck. Surgical details are described in the main body of text. Three female patients had undergone the procedure. Torticollis was resolve in all patients with complete restoration of ranage of motion. There were no postoperative complications, and patient satisfaction was high. We have reported three cases of mild CMT in adult female patients, who had undergone minimal-incision myotomy under local anesthesia. Outcomes were satisafactory with no morbidity to report. With careful patient selection, this method offers an alternate treatment option for adult CMT patients with mild symptoms.

Breastfeeding infants with congenital torticollis

Infants with unilateral sternocleidomastoid tension and associated craniofacial, spinal, and hip asymmetries may feed poorly. Anatomic and muscular asymmetry stress both biomechanics and state control, increasing the potential for difficulty latching and sucking. A combination of positioning modifications to allow the infant to maintain his or her comfortable head tilt and turn, supportive techniques to restore alignment of oral structures, and handling techniques to help activate the weak contralateral muscles have been effective in the author's practice. Lactation consultants can promote positioning and muscle activation strategies and encourage physical therapy referrals for infants who do not respond promptly to reduce the risk of craniofacial deformity and developmental problems.

Arthroscopic surgical treatment for neglected congenital muscular torticollis in adults

BACKGROUND

Congenital muscular torticollis (CMT) is the third most common congenital musculoskeletal anomaly. The efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. The aim of this retrospective study was to determine the efficacy of arthroscopic release of the sternocleidomastoid (SCM) muscle for the treatment of neglected CMT in adult cases.

METHODS

From April 2008 to July 2013, a total of 20 adult patients (9 men and 11 women) with a mean age of 23.0 years were surgically treated for neglected CMT with local anesthesia. The SCM muscle and clavicle were preoperatively marked. Through an artificial lacuna, an arthroscope and a radiofrequency probe were inserted. The sternal and clavicular attachments were dissected and divided via radiofrequency. Clinical evaluation was assessed using a modified Cheng and Tang score.

RESULTS

The operation was successfully completed in all the patients. Follow-up examinations from 12 to 40 months in the 20 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. There was no evidence of serious complications. The neck scars were no longer visible after several weeks. According to the modified Cheng and Tang scale, 11 patients displayed an excellent result and 9 patients had a good result.

CONCLUSIONS

Arthroscopic release of the SCM muscle with local anesthesia is a simple and effective way to surgically manage neglected CMT without any risk for either damage to the neurovascular structures or leaving visible scars.

Is sternocleidomastoid muscle release effective in adults with neglected congenital muscular torticollis?

BACKGROUND

Neglected congenital muscular torticollis is rare in adults but may be associated with pain and cosmetic problems. The efficacy of surgical correction in these patients has not been well established in the literature.

QUESTIONS/PURPOSES

We sought to describe (1) the primary goals that influenced adults with neglected muscular torticollis to seek surgical correction, (2) improvements of patients' function (specifically ROM) and radiographic parameters associated with deformities, (3) patient-derived outcomes using a previously published scale that includes function, and cosmesis, and (4) complications associated with sternocleidomastoid release in one surgeon's series of patients.

METHODS

We retrospectively reviewed the records of all adult patients who had surgical release of the sternocleidomastoid muscle between 2003 and 2011 by one surgeon and who were followed up for more than 1 year after surgery; 42 of these procedures were performed, and complete followup was available for 37 of them (88%). The mean age of the patients was 27 years (range, 18-48 years), and the minimum followup was 1.5 years (mean, 2.4 years; range, 1.5-4.7 years). The primary goal of the operation for each patient was determined to assess if it was met. Functional outcomes were assessed in terms of motion deficit: lateral flexion and rotation. Radiographic outcomes were assessed for cervicomandibular angle, lateral translation of the head and neck, and Cobb's angle of the cervicothoracic spine. The overall clinical results of surgery were assessed with the modified Cheng and Tang scoring system, and complications were tallied from a chart review.

RESULTS

The primary goals of surgery were cosmesis in 17 (46%) patients, pain in 11 (30%) patients, and function in nine (24%) patients. Patients for whom pain was the primary goal of surgery were older than the other patients. ROM and radiographic parameters associated with deformity consistently improved in these patients (p < 0.001 in all planes), and the overall results according to the modified Cheng and Tang scoring system indicated that 21 (57%) patients had an excellent result, 12 (32%) had a good result, and four (11%) had a fair result. There were no serious complications and no reoperations in these patients.

CONCLUSIONS

Sternocleidomastoid release was beneficial for the treatment of neglected congenital muscular torticollis in adults and was not associated with any serious complications. Surgical treatment led to cosmetic and functional improvements and relieved pain originating from the muscle imbalance brought about by the long-standing deformity.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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 0.3% to 2%. Owing to effective shortening of SCM on the involved side there is ipsilateral head tilt and contralateral rotation of the face and chin. This article reports a case of CMT in a 3½-year-old male child successfully managed by surgical release of the involved SCM followed by physiotherapy.

Is craniofacial asymmetry progressive in untreated congenital muscular torticollis?

BACKGROUND

Although craniofacial asymmetry is frequently involved in patients with congenital muscular torticollis, it has not been evaluated appropriately. The authors analyzed preoperative craniofacial asymmetry objectively and confirmed the relationship between craniofacial asymmetry and aging in congenital muscular torticollis patients who underwent surgical release.

METHODS

The authors retrospectively measured preoperative craniofacial asymmetry using the Cranial Vault Asymmetry Index and intercommissural angle and reviewed preoperative rotational and flexional deficit of neck movement for 123 congenital muscular torticollis patients who underwent surgical release at Ajou Medical Center from February of 2007 to February of 2011. The relationships among Cranial Vault Asymmetry Index, intercommissural angle, rotational deficit, flexional deficit, and age were analyzed. Mean values of dependent variables were compared after patients were grouped by age.

RESULTS

Mean age at operation was 82.5 months (range, 5 to 498 months). Seventy-one percent (n=87) of patients had a significant cranial asymmetry and 87 percent (n=107) had a significant facial asymmetry. In correlation analysis, intercommissural angle increased proportional to age (r=0.334, p=0.000), especially before 3 years (r=0.42, p=0.001). Cranial Vault Asymmetry Index was unrelated to age or rotational or flexional deficit. Rotational deficit decreased proportional to age (r=-0.229, p=0.032). By analysis of variance test, intercommissural angle and rotational deficit between the age groups were statistically significantly different (p<0.05).

CONCLUSIONS

In congenital muscular torticollis, facial asymmetry is progressive if the contracted sternocleidomastoid muscle is not released, although cranial asymmetry is already determined in those younger than 6 months. Early correction of torticollis should be considered to prevent progression of facial asymmetry in congenital muscular torticollis patients.

CLINICAL QUESTION /LEVEL OF EVIDENCE

Risk, III.

Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association

BACKGROUND

Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions.

KEY POINTS

Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations.

Management of congenital muscular torticollis in a child: a case report and review

Congenital muscular torticollis is a condition in which the sternocleidomastoid muscle is shortened on the involved side, leading to an ipsilateral tilt of the head and a contralateral rotation of the face and chin. Most of these patients present in infancy and are successfully treated with physical therapy. Occasionally, patients present in childhood at which time conservative management is rarely successful. Here we present a child with torticollis who was successfully managed with a unipolar release of the sternocleidomastoid. We then review the epidemiology, proposed etiologies, and various treatment options for torticollis and their rates of success.

Usefulness of diffusion tensor imaging in patients who showed sustained unexplainable clinical symptom of torticollis

To investigate corticospinal tract (CST) status using diffusion tensor imaging (DTI) in patients who had clinical symptom of torticollis but no definite cause of sustained symptom of torticollis. We evaluated 10 patients with sustained torticollis and 12 age-matched control subjects. All patients showed no specific fibromatosis coli findings on neck sonography. Even after intensive manual therapy, there was no improvement of clinical symptom of torticollis. DTI was performed using 1.5 T with a synergy-L Sensitivity Encoding (SENSE) head coil. Fractional anisotropy and apparent diffusion coefficient were measured using the region of interest method, and diffusion tensor tractography was conducted. We estimated the asymmetric anisotropic index (AA) and asymmetric mean diffusivity index (AD) to evaluate the asymmetry between right and left CSTs. All patients showed only torticollis symptom but no definite hemiplegic pattern on their extremities at initial evaluation. DTT, which was performed to reveal the reason of sustained asymmetric postural symptom showed hemiplegic pattern. The results of DTT corresponded to the delayed hemiplegic symptoms, which were found in the patients at second evaluation. AA and AD values between patients and control group were significantly different. Torticollis is usually caused by fibromatosis coli, but may be one of the symptoms of hemiplegia. DTI may be an additional technique for the early detection of hemiplegia in patients with sustained symptoms of unexplainable postural torticollis.

Clinical features and outcome of physiotherapy in early presenting congenital muscular torticollis with severe fibrosis on ultrasonography: a prospective study

BACKGROUND

It has been reported that ultrasonography (US) can detect the severity of congenital muscular torticollis (CMT), and severe fibrosis of the sternocleidomastoid (SCM) muscle noted on US is irreversible and likely to require surgery. Clinical outcome of CMT depends mainly on the patient's age, which is also associated with the severity of fibrosis as determined by US. However, there has been no well-designed study to elucidate the true relationship among these factors nor a definite consensus on treatment of young infants with severe fibrosis in the SCM compared with well-documented reports that late cases require surgery.

PURPOSE

The purpose of the current study was to investigate whether severity of SCM fibrosis on US is correlated with clinical severity and outcome of standardized physiotherapy in early presenting CMT.

METHODS

Fifty patients with a palpable neck mass, initial deficit of passive neck rotation (ΔROT) more than 10°, and age less than 3 months were classified into 4 US types according to the severity of fibrosis in the SCM and underwent standardized physiotherapy and regular assessment. Relationship between US types and 2 variables (ΔROT and treatment duration) and success rate of physiotherapy was assessed.

RESULTS

None of the cases was classified as type 4. Type 3 showed greatest ΔROT and longest mean treatment duration. Both variables showed a significant linear trend of association with US types by P for trend (P = .003, P < .001, respectively). Treatment was "successful" in 49 patients (98%).

CONCLUSION

In young infants with CMT, US can document severity; and an early and adequate physiotherapy is a good treatment option, particularly even in those with severe fibrosis.

Adult presentation of congenital muscular torticollis

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results.

Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.

Results of bipolar release in the treatment of congenital muscular torticolis in patients older than 10 years of age

PURPOSE

Neglected congenital muscular torticollis (CMT) is a common presentation in developing countries like India, with the primary concern of the patients being cosmesis. Little has been published regarding the management of such patients. The aim of our study was to evaluate the results of bipolar release in this age group.

METHODS

Over a period of five years, 14 patients older than ten years (range 10-19 years) with neglected CMT were operated on with bipolar release of sternocleidomastoid muscle and z-plasty lengthening of the sternal end. Postoperative protocol included head halter traction for three weeks followed by intensive physical therapy. Results were evaluated using a modified version of the system of Lee et al.

RESULTS

At an average follow-up of around three years (range 1-5 years), excellent results were noted in three patients, good in seven, fair in two, and poor in two. Postoperative improvements in range of motion, head tilt, chin deviation and cosmesis were noted in all patients, and these improvements were statistically significant. No surgery-related complications or recurrences requiring surgery occurred in any of the patients.

CONCLUSIONS

This study concluded that patients with CMT presenting after ten years of age definitely benefit from surgery, and that bipolar release is an adequate and complication-free method for such patients.

Complete tight fibrous band release and resection in congenital muscular torticollis

Congenital muscular torticollis (CMT) is caused by shortening of the sternocleidomastoid (SCM) muscle, which may lead to neck movement limitation and craniofacial deformity. The authors retrospectively reviewed clinical experiences of CMT at their hospital from February 2007 to June 2008. During the study period, 20 CMT patients underwent complete tight fibrous band release and resection. Mean patient age was 47.6 months at operation. Eighteen of the 20 patients started a programme of physical therapy preoperatively. All patients received well-controlled postoperative physical therapy and wore a soft neck collar to correct head position for at least 3 months. At 3 months postoperatively, passive ranges of neck motion were determined, and compared with those of uninvolved sides. Eighteen patients showed a full range of motion of neck rotation and lateral flexion, but one patient showed a 10 degrees limitation in lateral flexion, and another showed 10 degrees limitations of neck rotation and lateral flexion. The authors recommended that the described operative technique involving complete fibrous band release and resection, combined with intensive postoperative physical therapy and application of a soft neck collar, provides good functional and cosmetic results.

The role of congenital muscular torticollis in the development of deformational plagiocephaly

BACKGROUND

Numerous risk factors have been associated with the development of deformational plagiocephaly, although the etiology remains unclear. Torticollis and sternocleidomastoid imbalance are implicated, but reporting is variable. The authors sought to determine the incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly.

METHODS

The authors prospectively evaluated 371 infants with cranial asymmetry between 2002 and 2003. Demographic data and medical history were recorded, and a questionnaire was administered. Cranial asymmetry and head rotation were assessed, and variables were statistically analyzed.

RESULTS

Two-hundred two patients were included. Mean age at initial evaluation was 6.1 months (range, 3 to 16 months). Sixty-eight percent (n = 138) were male; 74 percent (n = 149) were flat on the right occiput; 14 percent (n = 28) were from a multiple pregnancy (24 twins, four triplets); 27 percent (n = 54) were premature; and four percent (n = 8) were syndromic. Ninety-three percent (n = 188) of parents did not notice flattening at birth. Ninety-two percent (n = 186) recalled a preferential head position after birth, and in 95 percent of these infants (n = 177 of 186) this improved with age. Only 24 percent (n = 48) of infants had been previously diagnosed or treated for torticollis. Mean cranial asymmetry was 12.5 mm (range, 8 to 25 mm). Ninety-seven percent (n = 195) of infants had head rotational asymmetry of 15 degrees or greater, with more rotation to the flat side. The mean rotational difference was 24 degrees (range 0 to 60; SD 9.8). There was a negative correlation (p = 0.004) between age and head rotational asymmetry (i.e., younger patients exhibited greater asymmetry) and a positive correlation (p = 0.043) between cranial asymmetry and head rotational asymmetry.

CONCLUSIONS

The incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly is underreported. Because this condition improves rapidly during early infancy, the findings may be subtle and evidenced only by a history of preferential head rotation. The major cause of deformational plagiocephaly is limited head mobility in early infancy secondary to cervical imbalance.

Is surgery recommended in adults with neglected congenital muscular torticollis? A prospective study

BACKGROUND

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.

METHODS

From January 2003 to June 2007, 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. Radiography and the modified Lee's scoring system which included function and cosmesis, were used to measure the surgical results. Complications were also recorded.

RESULTS

Four cases were lost during follow-up. Of the remaining 14 patients, 10 cases were males and 4 females. The age at operation ranged from 18 to 32 (average 21.9) years. The mean follow-up period was 2.5 years (range 1-5 years). Excellent results were noted in 7 patients, good in 5, and poor in 2 patients. Significant improvement (>10 degrees) of the cervico-thoracic scoliosis was noted only in 3 of 10 patients.

CONCLUSION

Patients with congenital muscular torticollis can benefit from surgical treatment even in adulthood. Surgical bipolar sectioning of the sternocleidomastoid muscle should be considered even in adults with irreversible facial and skeletal deformities. The surgery restores the range of neck motion and resolves the head tilt; therefore it can improve the quality of life. This procedure is an effective and relatively complication-free method.