Torticollis, also known as wry neck, is a clinical examination finding of head tilt with neck torsion ^1,5. It is not a diagnosis in itself, and there is a wide range of underlying causes ^1,7.

Terminology

Terminology around torticollis is inconsistent with overlapping definitions for congenital muscular torticollis, atlantoaxial rotatory fixation (AARF), and sternomastoid imbalance ^4,7; however, these terms reflect a specific diagnosis ^1,7 rather than the clinical examination finding.

Epidemiology

Torticollis is most common in children but can occur at any age and even antenatally ^4,7. 

Pathology

Torticollis can be acute (<1 week) or chronic (>1 week). Up to 20% of chronic torticollis may be due to non-muscular conditions (e.g. skeletal abnormalities) ².

Aetiology

Up to 80 causes of torticollis have been published, and associated symptoms/signs are important in narrowing the possible causes ⁷.

Congenital causes are more common in younger children, with congenital muscular torticollis the most common cause in children <1 year old ^1,5. Acquired causes are more common in older children and adolescents ¹. In adults, muscle injury is the most common cause ¹.

Congenital

• musculoskeletal

  • congenital muscular torticollis occurs in infants <12 months old ^1,5,7

    • sternocleidomastoid muscle (SCM) tightening

    • fibromatosis colli

    • postural torticollis: without mass or SCM tightening

  • fusion anomalies, e.g. atlanto-occipital assimilation, cervical vertebral fusion, hemivertebrae ⁵

  • ligamentous laxity as seen in Down syndrome, achondroplasia, Marfan syndrome ^1,7

  • atlanto-occipital subluxation ⁵

• CNS

  • syringomyelia

  • ocular abnormalities, e.g. congenital strabismus/nystagmus

Acquired

• idiopathic

• musculoskeletal

  • trauma, e.g. occipital condyle fracture, facet joint dislocation, muscle injury/spasm ^1,7

  • infection, e.g. osteomyelitis ^1,7

  • inflammatory, e.g. juvenile rheumatoid arthritis ^1,7

  • atlanto-axial rotatory fixation (rare) ^1,7

    • idiopathic

    • post-traumatic

    • iatrogenic (e.g. post ENT surgery)

    • post-infective (Grisel syndrome) from sinusitis, otomastoiditis, retropharyngeal abscess, etc

• CNS, e.g. demyelination, Chiari malformation, neurogenic tumours, spinal cord tumours ^1,5

• medication side effect, e.g. acute dystonias including torticollis are recognised extrapyramidal side effects seen with antipsychotic medications

Associations

• occipital plagiocephaly: generally considered secondary to torticollis ⁷

Radiographic features

The imaging strategy is highly dependent on the age of the patient, clinical presentation (painful vs painless; intermittent vs constant), and any associated musculoskeletal or neurological examination findings ^1,5,7.

However, in infants <12 months old who present with a non-traumatic torticollis, cervical spine radiographs are generally not indicated due to a very low diagnostic yield ^5,6.

History and etymology

The word torticollis is derived from the Latin torsus meaning twisted and collum meaning neck ⁷.