STRETCHING, POSITIONING AND A HIP CHECK - REFER EARLY (RECOGNITION & REFERRAL)
Congenital Torticollis - StatPearls (NCBI Bookshelf NBK549778) - https://www.ncbi.nlm.nih.gov/books/NBK549778/
No medicine is used. The intervention is physiotherapy started early, and the two things primary care must not miss are the hip that comes with it and the head tilt that is not muscular at all.
- WHAT IT IS - the sternocleidomastoid on 1 side is contracted or fibrosed, so the head inclines towards that side while the face and chin rotate to the other. In other words, the head tips towards the tight muscle and the chin turns away from it.
- TIMING SEPARATES IT FROM EVERYTHING ELSE - the congenital form is there at birth or appears in the first weeks, and it has to be told apart from the acquired forms. Acquired torticollis can start at any age, on the back of a congenital skeletal anomaly, injury, infection, inflammation in a neighbouring structure, a tumour, or an ocular or neurological dystonia. A neck that twists for the first time in an older child who was normal until then is not this diagnosis and needs urgent assessment.
- THE LUMP IN THE NECK IS PART OF IT - a painless mass felt in the side of the neck, within the sternocleidomastoid, showing up in a neonate at about 2 to 3 weeks. It may go on growing for 2 months, to roughly the size of an almond, and then start to regress; it can be gone altogether by the eighth month. Painless, within the muscle, in a young infant - a painful or enlarging neck mass is a different problem.
- CHECK THE HIPS. THIS IS THE MISS THAT COSTS A CHILD A JOINT - congenital hip dysplasia comes with congenital torticollis in up to 20% of cases. The article puts the incidence at roughly 15%, while noting other studies reporting hip dysplasia in 1 of every 5 babies with congenital torticollis. Its instruction: examine the hips regularly and scan them by ultrasound at 4 to 6 weeks of age. A plain radiograph of the hips does the same job at 4 to 6 months.
- EXAMINE THE EYES AND THE NEUROLOGY BEFORE ACCEPTING THE DIAGNOSIS - neurological and auditory assessment is fundamental, to rule the other differentials out. Where the examination finds no contracture in the muscle and the joint range is intact, that suspicion sends the child to ophthalmology. A tilt with a normal, supple neck is ocular until proven otherwise. Weakness of an oculomotor muscle - the lateral rectus, say, or the superior oblique - can mean the torticollis is a compensation, adopted to see better.
- THE SERIOUS DIFFERENTIALS THE ARTICLE NAMES - vertebral anomalies, hemivertebrae and Klippel-Feil syndrome among them; Arnold-Chiari malformation; syringomyelia; a tumour of the cervical spine; a brain tumour. Anything with abnormal neurology, pain, or an onset outside the newborn period goes to a paediatrician rather than to a physiotherapist.
- TREATMENT IS PHYSIOTHERAPY, AND EARLY IS THE WHOLE POINT - physical therapy is the cornerstone, congenital or acquired alike. Treated properly, 90% to 95% of children are improving before their first birthday, and 97% improve where treatment starts inside the first 6 months. A palpable mass is itself a trigger to begin - the article calls it an important indicator for starting by the second month of life.
- WHAT THE PARENTS ACTUALLY DO AT HOME - manual stretches in flexion, extension and lateral rotation, at least 3 times a week, 15 stretches to a set. Hold each one for 1 second. Between repetitions, pause 10 seconds. Then the positioning: build it into the daily routine, at feeds among other times, turning the chin towards the affected shoulder. And supervised time on the tummy while the baby is awake, which helps the motor skills develop in prone.
- THE FLAT HEAD IS A CONSEQUENCE, NOT A SEPARATE COMPLAINT - because the baby favours one side to sleep on, constant pressure on the head remodels the cheekbones, and facial hemihypoplasia or plagiocephaly follows. Treating the neck early is what prevents it - craniofacial asymmetry improves too, and improves most where treatment started early.
- WHEN PHYSIOTHERAPY IS NOT ENOUGH - a collar is an option later: the TOT collar - Tubular Orthosis for Torticollis - is recommended once a child is over 4 months of age. Surgery comes last, and may be indicated where 6 months of manual stretching has produced no improvement. Refer rather than keep stretching indefinitely.
- WHAT TO TELL THE PARENTS - come back to the paediatrician, or to the physiotherapist, on noticing any swelling of the neck muscles, or any deformity of the neck. Say why it matters: a diagnosis made late can end in surgery, and the asymmetry of the face and skull can persist.