Congenital muscular torticollis and the associated craniofacial changes

Congenital torticollis is a condition that results in the deviation of a ch ild's head to one side, with accompanying limitation in the range of motion of the neck. Although of multiple etiologies, the most common is a primary idiopathic condition resulting in fibrosis and scarring of the sternocleio domastoid muscle. The clinical experience with torticollis at the Variety C enter for Craniofacial Rehabilitation at the Institute of Reconstructive Pl astic Surgery of the New York University Medical Center from 1992 to 1997 w as retrospectively reviewed. Clinical records, standardized medical photogr aphs, and cephalometric radiographs of the affected patients were examined. There was a total of 16 patients with a mean age of 33 months at the time of presentation. All patients were initially started on a program of physic al therapy. Four patients (25 percent) subsequently underwent surgical corr ection consisting of a bipolar sternocleiodomastoid release/resection; the age of the surgical subgroup at the time of initial presentation was signif icantly greater than that of the nonsurgical patients (8 years, 4 months ve rsus 12 months). Of the patients for whom longitudinal records were availab le (11 of 16), the mean follow-up period was 48 months. The head tilt impro ved in all patients-surgical and nonsurgical-but it was only completely cor rected in 38 percent of the physical therapy-only patients and 25 percent o f the surgical patients. All patients in the series exhibited some degree of facial asymmetry, most commonly manifest as mild retrusion of the ipsilateral forehead and zygoma with shearing of the ipsilateral auricular helix in a posterior and inferio r direction. In the more severe cases, there were also changes in the shape and position of the orbit, nose, and mandible. However, in only one case w as the asymmetry sufficiently severe to warrant surgical reconstruction of the affected skeleton. These changes are particularly well demonstrated in the case of the 18-year-old man in this series presenting for treatment of a previously neglected torticollis. Cephalometric analysis revealed a reduc tion in vertical facial height on the affected side. Evaluation of this clinical series would indicate that younger patients may be effectively managed with therapy alone; patients presenting for treatme nt at a later age are more likely to require surgical release/resection.