Torticollis

What is Torticollis?

Torticollis, often called wry neck, is an abnormal head and neck posture in which the head tilts to one side and the chin rotates to the opposite side. In infants, the most common cause is congenital torticollis, which involves shortening and fibrosis (scarring) of the sternocleidomastoid muscle. In contrast, torticollis in adults most commonly refers to cervical dystonia, an adult-onset focal dystonia that causes abnormal neck posturing, tremor, and pain. Spasmodic torticollis is an older term for cervical dystonia.

Congenital muscular torticollis is usually evident by two to four weeks of age. Early recognition is essential for timely referral to specialized care and successful intervention. Understanding the nature of the posture helps clinicians distinguish between muscular and neurological drivers. Comprehensive evaluation of the abnormal head position guides the appropriate torticollis treatment pathway.

What causes Torticollis?

In congenital muscular torticollis, proposed contributors include intrauterine positioning and birth trauma, although the exact mechanism is not fully established. Spasmodic torticollis or cervical dystonia is thought to reflect dysfunction in a motor control network that includes the basal ganglia and other brain regions. These circuits are responsible for coordinating smooth, involuntary movements and postural control.

In children, acquired torticollis may result from muscle injury or inflammation, upper respiratory or deep neck infection, atlantoaxial rotatory subluxation, ocular disorders, or medication-induced dystonia. Ocular and neurologic disorders can also cause secondary torticollis and should be considered when the presentation is atypical. Ocular torticollis is usually a compensatory head posture adopted to improve visual alignment or reduce diplopia. The differential for torticollis symptoms includes atlantoaxial rotatory subluxation, retropharyngeal abscess, ocular torticollis, medication-induced dystonia, and posterior fossa lesions.

What are the signs and symptoms of Torticollis?

Infants with congenital muscular torticollis typically present with head tilt and limited neck range of motion. Parents sometimes notice a firm, palpable mass within the infant’s sternocleidomastoid muscle. Older children with acquired torticollis often present with painful neck stiffness or sudden head tilt, whereas adults with cervical dystonia may have patterned muscle contractions, tremor, and pain. These abnormal contractions lead to compensatory shoulder elevation.

The onset of torticollis symptoms can be insidious in adulthood, with the severity of contractions fluctuating throughout the day. Infectious or traumatic torticollis in children often has an acute onset. Secondary forms caused by infection or neoplasm may include systemic symptoms like fever or weight loss. These red flags signal the need for urgent diagnostic imaging to rule out serious underlying pathology. Observing these manifestations within the proper age context helps differentiate benign musculoskeletal causes from complex neurologic etiologies.

How is Torticollis diagnosed?

Evaluation depends on age and suspected cause and should include history of onset, trauma, infection, medication exposure, ocular symptoms, and neurologic symptoms. The physical examination focuses on active and passive neck range of motion and seeks associated neurologic deficits. In infants with suspected congenital muscular torticollis, ultrasound of the neck can help characterize sternocleidomastoid thickening or fibrosis. For atypical or refractory cases, radiographs or MRI assess cervical spine anomalies and rule out posterior fossa lesions in the brain.

When clinicians suspect cervical dystonia (previously spasmodic torticollis), they must perform a detailed neurologic examination to identify abnormal posturing, tremor, and sensory tricks. Electromyography (a test of muscle electrical activity) is not usually required for diagnosis but may help guide muscle selection for botulinum toxin injections in selected cases. Laboratory studies are rarely necessary unless the provider suspects systemic disease or an underlying infection. These clinical findings help initiate a successful torticollis treatment plan.

How is Torticollis treated?

Early physical therapy for a baby with torticollis emphasizes manual stretching, range-of-motion exercises, and increased tummy time. Caregiver education regarding positioning during feeding, play, and daily handling supports gradual restoration of a more symmetric head posture. If there is a persistent limitation of neck motion, significant plagiocephaly or facial asymmetry, or failure to improve after prolonged physical therapy, referral for surgical evaluation may be appropriate.

In cases of spasmodic torticollis, the primary treatment is botulinum toxin injections into overactive neck muscles. These injections inhibit acetylcholine release to reduce the frequency and intensity of dystonic contractions. For torticollis in adults driven by cervical dystonia, botulinum toxin is first-line treatment, while oral medications may be used as adjuncts in selected cases. Severe, treatment-refractory dystonia may require deep-brain stimulation or selective peripheral denervation to restore a functional head position.

What are the most important facts to know about Torticollis?

• Torticollis is an abnormal head and neck posture in which the head tilts to one side, and the chin rotates to the opposite side
• Congenital torticollis results from sternocleidomastoid shortening and fibrosis, while torticollis in adults is usually caused by cervical dystonia (previously called spasmodic torticollis).
• Early identification of torticollis symptoms in infants allows for successful conservative management through physical therapy and repositioning.
• A torticollis baby requires manual stretching and tummy time, whereas torticollis in adults often relies on botulinum toxin or neuromodulators.
• Effective torticollis treatment depends on identifying the underlying cause and recognizing red flags such as fever, trauma, neurologic deficits, or persistent pain.