Torticollis in children: an alert symptom not to be turned away.

Abstract

Dear Editor: In their study, Tumturk et al. investigated the spectrum of underlying disease in children with torticollis and made a good contribution for a better understanding of accompanying pathologies in pediatric cases presenting with clinical symptom of torticollis. However, while discussing torticollis in pediatric neurosurgery cases, the entities Bdeformational plagiocephaly^ and Bsynostotic plagiocephaly^ should also be highlighted, I believe. These two conditions are frequently encountered in pediatric neurosurgery practice, and it is not unusual for those cases to be presented with the clinical symptom of torticollis. Torticollis, literally interpreted as Btwisted neck,^ has been applied to nearly any type of abnormal head tilt or rotation. Torticollis can be caused by cervical hemivertebrae, atlanto-axial subluxation, acquired sternocleidomastoid spasm, exotropia, and congenital muscular torticollis [1, 2]. Congenital muscular torticollis is the most common cause of head tilt and asymmetrical head rotation and is estimated to occur in 0.3 to 2.0 % of live births [3]. This condition is believed to result from intrauterine constraint of head movement, which interferes with cervical muscle development and strength [4]. Being one of the most common musculoskeletal problems in children, congenital muscular torticollis is known to be frequently accompanied by deformational plagiocephaly. An association between deformational plagiocephaly and torticollis has been observed by many investigators [4–6]. In one large series of congenital muscular torticollis, craniofacial asymmetry was noted in 90.1 % of patients [1]. In a multicenter study, the incidence of torticollis in plagiocephalic infants has been reported to range between 5 and 67 % [7]. In their study concerning the incidence of torticollis in deformational plagiocephaly, Rogers GF et al. [6] showed that nearly all of their plagiocephalic patients had some evidence of cervical imbalance, and 24 % had been diagnosed as having torticollis before their initial evaluation. They also demonstrated a positive correlation between the magnitude of head rotational asymmetry and occipital flattening (i.e., infants with more severe torticollis had more severe plagiocephaly). Thus, it is important to keep in mind that torticollis is a common associated finding in infants with deformational plagiocephaly [4–6]. However, this condition may be underreported because the muscular imbalance improves during the first year of life [2, 5]. Anterior plagiocephaly due to unicoronal craniosynostosis is also commonly associated with an ipsilateral hypertropia and a contralateral head tilt. It should be kept in mind that, in synostotic anterior plagiocephaly cases, the shortening of the orbital roof with retroplacement of the trochlea may result in superior oblique palsy which may lead to ocular torticollis [8, 9]. Recently Matalia et al. reported two siblings with synostotic plagiocephaly and simulated superior oblique palsy with ocular torticollis and suggested that synostotic plagiocephaly should be included in the differential diagnosis of familial congenital superior oblique palsy [9]. Deformational plagiocephaly and synostotic plagiocephaly should always be kept in mind while considering the spectrum of underlying disease in pediatric cases presenting with clinical symptom of torticollis. * Volkan Etus drvolkanetus@yahoo.com