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A 6-week-old female infant presents with the neck deformity and palpable mass shown in Figure A. She has had persistent lateral tilting of her head to the right since birth, and rotation of the neck is restricted. In this age group, what is the most common cause of this rotational abnormality?
Congenital muscular torticollis
Atlantoaxial rotatory displacement
Paroxysmal torticollis of infancy
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Congenital muscular torticollis (CMT) is the most common cause of torticollis in infancy. Neurologic disorders and osseous abnormalities, such as Klippel-Feil, are less common. Ultrasonography is considered the modality of choice for differentiating (CMT) from other more serious pathologies in the neck when a palpable mass is present. The initial treatment of CMT is conservative, and good outcomes can be expected in the majority of these cases. Tang et al used US to examine affected sternocleidomastoid muscles in patients with CMT classified as having one of four types of fibrosis. They determined the change in fibrosis type over time and concluded that CMT is a dynamic disease which can be accurately assessed and followed by ultrasonography. Benign paroxysmal torticollis is a self-limiting condition occurring during infancy. It resolves by the age of two to three years. Paroxysmal torticollis of infancy is a rare disorder characterized by periodic episodes of torticollis which are associated with pallor, agitation and ataxia. The etiology is unknown and no treatment is effective, however the condition is usually benign and self-limiting.
Tang SF, Hsu KH, Wong AM, Hsu CC, Chang CH
Clin. Orthop. Relat. Res.. 2002 Oct;(403):179-85. PMID: 12360024 (Link to Abstract)
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Tightness in which of the following muscles has been implicated as an etiology for congenital muscular torticollis?
Tightness of the sternocleidomastoid muscle leading to a stiff and tilted neck is associated with the muscular variety of congenital torticollis. The differential diagnosis of the wry neck however includes sequelae to inflammatory, ocular, neurologic or orthopedic diseases so therefore a thorough and systematic work-up is warranted, including a complete physical and neurologic examination and cervical spine radiographs. The treatment for the muscular variety is observation and physical therapy (stretching: lateral head tilt away from the affected side and chin rotation toward the affected side), then botox or sternocleidomastoid muscle lengthening for refractory cases. Overall, it is important to differentiate muscular from nonmuscular torticollis because the muscular type is benign while the nonmuscular type could be potentially life threatening. The illustration below shows an example of muscular torticollis.
COVENTRY MB, HARRIS LE.
J Bone Joint Surg Am. 1959 Jul;41-A(5):815-22. PMID: 13664717 (Link to Abstract)
Curr. Opin. Pediatr.. 2006 Feb;18(1):26-9. PMID: 16470158 (Link to Abstract)
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