Congenital muscular torticollis has been known since ancient times and was described by Horace and Suetonius. Pathology develops as a result of dysplastic changes in the sternocleidomastoid muscles and ranks second among the most common congenital childhood defects, the percentage of its occurrence is up to 12%.
Reasons
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The presence of spindle-shaped swelling in the muscle is considered as a hemorrhage resulting from the passage of the baby's head through the birth canal, due to tears, excessive stretching of dysplastic muscles.
Symptomatics, forms
Clinical manifestations of congenital muscular torticollis depend on its form and the age of the child. Specialists classifymild, moderate, severe forms of the disease.
Quite often mild and moderate forms of torticollis are not diagnosed by specialists.
Children are admitted for treatment when organic changes in the facial skeleton appear. Severe forms of pathology are easy to diagnose. Typical symptoms of congenital torticollis:
- Baby keeps head tilted to the side.
- Chin turned away from head tilt.
Passive attempts to return the head to a straight position are unsuccessful due to the fact that the sternocleidomastoid muscles are significantly tense.
In the middle third of the muscle, a spindle-shaped thickening is palpable and visualized, which is located in the abdomen of the muscle and does not solder with adjacent tissues.
As the child grows, symptoms begin to increase, muscle elasticity decreases.
After a year of life, the asymmetry of half of the skull and the facial skeleton appears on the side where the head is tilted.
Facial asymmetries
Children of 3 years old have clearly visible asymmetries of the face. The shoulder blades and shoulder girdle are also asymmetrical, on the side of the torticollis they are slightly higher than on the other side.
Muscles are hypotrophic compared to the he althy side, except for the middle third, where a spindle-shaped thickening is palpable.
The asymmetry of the shoulder blades and shoulder girdle is caused by the contracture of the anterior scalene and trapezius muscles. Older children begin to developupper thoracic and cervical scoliosis from the side of the torticollis.
Examination of the child allows you to clearly determine the presence of facial asymmetry from the side of the torticollis, as there is a narrow eye socket, a flattened superciliary arch, located slightly lower than on the he althy side.
Underdevelopment and flattening of both jaws
In addition, there is underdevelopment and flattening of both jaws. On the side of the torticollis, the ear lobe is located closer to the shoulder girdle.
The main task of doctors is the diagnosis of muscular torticollis in the maternity hospital and the elimination of pathology until the child reaches one year. This will prevent the development of deformation of the head and skeleton of the face.
Differential Diagnosis
It is necessary to differentiate congenital pathology first of all from a congenital additional wedge-shaped vertebra in the cervical spine.
A wedge-shaped congenital vertebra differs from torticollis in that the child's head is tilted to the side in this case, but the chin is not turned in the opposite direction.
Besides, the attempt to move the head to the normal position reveals the obstruction, and there is no tension on the sternocleidomastoid muscle - it remains relaxed. This is the main difference between torticollis.
Also, congenital muscular torticollis should be differentiated from spastic, which often manifests itself in cerebral palsy. In the case when cerebral palsy is manifested by typical symptoms, a diagnostic error does not occur. Diagnostic errors occur if cerebral palsy has an erased form. Prevent misdiagnosisallows a thorough examination of the child.
In addition, differential diagnosis is done to distinguish congenital torticollis from polio. In such cases, paresis or paralysis of the muscles develops. Congenital does not cause paralysis of the muscle, paralysis of the muscles of the limbs is also absent.
It is also necessary to differentiate muscular torticollis in children from dermatogenic torticollis resulting from injuries, burns.
There is also such a pathology as desmogenic torticollis, which occurs against the background of inflammation in the neck (lymphadenitis, phlegmon).
Differentiation is also required from reflex torticollis resulting from inflammatory processes in the middle ear. In this case, a careful examination of the patient, a thorough history taking is necessary.
Klippel-File Syndrome
Klippel-File syndrome is a congenital malformation of the vertebrae in the cervical region. In some cases, the epistrophy and the atlas are fused with the vertebrae located below, while there is no fusion of their arches. In other cases, there is a synostosis of the atlas and the occipital bone, while all the vertebrae of the neck are fused together by the cervical ribs or additional wedge-shaped vertebrae.
These children have a clinically short neck, and the impression is that the head is fused to the body. At the same time, such a low position of the limit of the scalp is noted that a transition of the hairline to the shoulder blades is observed. The head in this case is tilted to one side and forward, the chin is in contact withchest, there is a pronounced asymmetry of the skull, face. There is no movement in the cervical spine.
In older children, kyphosis or scoliosis develops, there is an asymmetric position of the shoulder girdle, a high location of the shoulder blades. There are paralysis, paresis, sensory disturbances in the upper limbs. The presence of these symptoms allows us to judge the absence of congenital torticollis.
It is also necessary to differentiate congenital muscular torticollis (ICD 10 - Q68.0) from the cervical ribs, which manifest as swelling in the supraclavicular region and impaired neurovascular conduction in one (with unilateral pathology) or both (with bilateral pathology)) hands - paralysis, paresis, disappearance of the pulse, impaired sensitivity, skin changes, cold snap.
Bilateral cervical ribs cause low drooping of the shoulders. It seems that the shoulders continue the neck. At the same time, the head is tilted to the side, and scoliosis of the cervicothoracic spine is manifested.
To exclude the occurrence of a diagnostic error will allow a thorough examination, examination, a full history.
Shereshevsky-Turner Syndrome
Also, muscular torticollis (ICD 10 - Q68.0) must be differentiated from pterygoid neck (Shereshevsky-Turner syndrome).
This congenital malformation is clinically manifested by the formation of unilateral or bilateral skin folds on the lateral surface of the neck.
Often the pterygoid neck is combined with other congenitalpathologies - flexion contracture of the fingers, hip dislocation, dysplasia.
Examination of a newborn reveals stretched skin folds located on the lateral surface of the neck from the middle of the shoulder girdle to the mastoid process. There is also a hardening of the child's face, deformation of the auricles, a short neck. Such symptoms are absent in congenital torticollis.
It is also necessary to differentiate pathology from Grisel's torticollis. This disease always occurs as a result of an inflammatory process in the nasopharynx, tonsils, accompanied by high fever. In this case, the inflammation spreads to the atlanto-epistrophic joint, resulting in subluxation of the atlas. Such a disease occurs most often in girls aged 6-11 years who have an asthenic constitution and a developed lymphatic system, through which the infection spreads.
The clinical manifestations of Grisel's torticollis are as follows: the head is tilted to the side and turned in the opposite direction, palpation reveals the protrusion of the spinous process of C11. Examination of the pharynx reveals the presence on its posterior superior surface of a protrusion at the level of the atlas, which is somewhat displaced upward and forward. This protrusion changes its size when the child turns his head.
Tilting the head, extension and flexion of the neck towards the torticollis is free, in the opposite direction it is severely limited, causing pain.
Rotational movement of the head is limited, causes pain, occurs inregion of the lower cervical vertebrae. An x-ray picture should be taken with Grisel's torticollis through the mouth. This will allow diagnosing the subluxation of the atlas and its rotation around the vertical.
Therapy
Treatment of muscular torticollis should begin after the fusion of the umbilical ring occurs. The mother should ensure that in bed the child lies on the side of the curvature, and the pillow should tilt the head to the opposite side.
Treatment of muscular torticollis is important to start in a timely manner.
It is also necessary to place the bed in such a way that the toys and the light are on the opposite side of the torticollis. In this case, the child will turn his head, stretching the dysplastic muscle.
Permanent correction of the head with muscular torticollis involves the use of cotton-gauze pads first, placed from the side of the torticollis, and then (1 month of life) - the Shants collar, applied after redressing. Redressing should be carried out up to 5 times a day, each of them should take up to 15 minutes. By the time of discharge from the maternity hospital, the mother should learn the technique of redress.
Redressing
The child must be laid on the table, on his back, placing his arms along the body. They are held by their mother or an assistant.
The doctor approaches the child from the side of the head, puts both hands on the cheeks and head and tries to bring it to a normal position with increasing force, but smoothly, while turning the chin to the side of the torticollis.
This position allows you to stretch the dysplastic muscle as much as possible. It is important to ensure thatwhile redressing, the baby's head did not tilt forward.
Perform redress for the treatment of congenital muscular torticollis for 5-10 minutes. Up to 5 procedures should be carried out per day. After it, the head is fixed with cotton-gauze pads, fixed with a bandage, in the most corrected state.
After the child's skin is finally formed (2.5-3 months from birth), paraffin applications are prescribed to thicken the dysplastic muscle and improve its elasticity.
When the baby reaches 2 months, you can start using the Shants collar to fix the head.
Therapy is carried out by gradually stretching the muscle to completely eliminate torticollis before the age of one. This approach is almost always effective for mild to moderate muscle torticollis.
Surgical treatment
It is not always possible to completely correct muscular torticollis in an infant with a severe form, therefore, at the age of 10-12 months, the child is prescribed surgical intervention.
An operation performed at this age helps prevent facial deformity.
Manipulation under anesthesia. The child is placed in the supine position, the assistant surgeon aligns the position of the head as much as possible, as a result of which the legs of the muscles are stretched.
Parallel to the tense muscles above the clavicle, the skin and soft tissues are cut, the sternal and clavicular muscle legs are isolated, the protectors are alternately brought under them, after which they are cut. Thencarefully cross the posterior wall of the tendon sheath.
Another incision is made above the mastoid process, the beginning of the muscle is isolated, it is crossed at the beginning transversely.
After that, the child's head is brought into a hypercorrective position, both incisions are sutured, aseptic dressing is made and a Shants collar is applied. It is important that the head is fixed in the overcorrection position.
What other treatment can be given for congenital torticollis?
If the child is 8-9 years old, then he is recommended to apply a thoraco-cranial plaster cast. After 2 weeks, physical therapy should begin. The Shants collar should be applied within 3 months after each exercise therapy session. With proper treatment and rehabilitation, there is a restoration of strength, performance, muscle endurance, as well as a stable head position. It is important to follow all the doctor's recommendations, this will correct the pathology in time and prevent the deformation of the child's face.
Massage for torticollis is an effective treatment and should be prescribed by a doctor. The purpose of this procedure is to activate blood circulation and lymph flow, as well as to promote muscle relaxation where they are clamped. Massage sessions will help them assume a natural position.
