Congenital Muscular Torticollis and the Associated Craniofacial Changes

Congenital torticollis is a condition that results in the deviation of a child's head to one side, with accompanying limitation in the range of motion of the neck. Although of multiple etiologies, the most common is a primary idiopathic condition resulting in fibrosis and scarring of the sternocleiodomastoid muscle. The clinical experience with torticollis at the Variety Center for Craniofacial Rehabilitation at the Institute of Reconstructive Plastic Surgery of the New York University Medical Center from 1992 to 1997 was retrospectively reviewed. Clinical records, standardized medical photographs, and cephalometric radiographs of the affected patients were examined. There was a total of 16 patients with a mean age of 33 months at the time of presentation. All patients were initially started on a program of physical therapy. Four patients (25 percent) subsequently underwent surgical correction consisting of a bipolar sternocleiodomastoid release/resection; the age of the surgical subgroup at the time of initial presentation was significantly greater than that of the nonsurgical patients (8 years, 4 months versus 12 months). Of the patients for whom longitudinal records were available (11 of 16), the mean follow-up period was 48 months. The head tilt improved in all patients—surgical and nonsurgical—but it was only completely corrected in 38 percent of the physical therapy-only patients and 25 percent of the surgical patients. All patients in the series exhibited some degree of facial asymmetry, most commonly manifest as mild retrusion of the ipsilateral forehead and zygoma with shearing of the ipsilateral auricular helix in a posterior and inferior direction. In the more severe cases, there were also changes in the shape and position of the orbit, nose, and mandible. However, in only one case was the asymmetry sufficiently severe to warrant surgical reconstruction of the affected skeleton. These changes are particularly well demonstrated in the case of the 18-year-old man in this series presenting for treatment of a previously neglected torticollis. Cephalometric analysis revealed a reduction in vertical facial height on the affected side. Evaluation of this clinical series would indicate that younger patients may be effectively managed with therapy alone; patients presenting for treatment at a later age are more likely to require surgical release/resection.