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Wry Neck (Torticollis)

A case of torticollis - head tilted to one side, chin pointing to the opposite side

Clinical appearance of torticollis - S Das Manual on Clinical Surgery

Definition

Torticollis (wry neck) is a deformity in which the head is bent to one side while the chin points to the other side. The key biomechanics: the head tilts toward and rotates away from the tight sternocleidomastoid (SCM) muscle. In long-standing cases, there is facial atrophy on the affected side - the distance from the outer canthus of the eye to the angle of the mouth is smaller, the eyebrow is less arched, the nose somewhat flattened, and the cheek less full.

Classification / Varieties

S Das Manual on Clinical Surgery lists the main varieties:

Type	Key Features
(a) Congenital	History of difficult labour; sternomastoid "tumour" (fibrotic nodule); affected muscle feels firm and rigid
(b) Traumatic	Fracture-dislocation of the cervical spine
(c) Rheumatic	Sudden appearance after exposure to cold or draught
(d) Inflammatory	E.g. from inflamed cervical lymph nodes (Grisel syndrome)
(e) Spasmodic	SCM of affected side + posterior cervical muscles of opposite side in sustained spasm; a form of cervical dystonia
(f) Compensatory	E.g. from scoliosis, or defect in sight (ocular torticollis)
(g) Pott's disease	Tuberculosis of the cervical spine
(h) Contracture	After burns, ulcers, skin scarring

Congenital Muscular Torticollis (CMT)

This is by far the most common type.

Pathogenesis

Proposed causes (Campbell's Operative Orthopaedics 2026):

Malposition of the fetus in utero / intrauterine constraint
Intrauterine or perinatal compartment syndrome of the SCM (Davids, Wenger, Mubarak hypothesis)
Birth trauma, vascular injury, infection

The result is fibrosis and contracture of the SCM muscle, sometimes with a palpable fibrotic nodule ("sternomastoid pseudotumour"), which typically appears in the first 6 weeks of life. It is associated with congenital hip dysplasia in up to 20% of cases and with breech positioning.

Diagnosis

Clinical: ipsilateral head tilt + contralateral chin rotation
The palpable fibrotic nodule within the SCM typically confirms the diagnosis without further imaging
When diagnosis is in doubt or neurologic findings exist: cervical spine X-rays, or MRI/CT
Ultrasonography is useful to evaluate SCM thickness (>5 cm correlates with poorer response to stretching) and to predict which infants will need surgery
Facial asymmetry (plagiocephaly) develops if untreated; the frontooccipital skull diameter may decrease

Treatment

Nonoperative (first-line):

Stretching exercises - ideally started before 3-4 months of age
Results: 92-100% achieve full passive neck rotation; only 1% require surgery if treated this early
For every month treatment is delayed, the chance of surgery increases
If CMT persists beyond the first year, nonoperative treatment is rarely successful
Botulinum toxin type A injection combined with physical therapy may improve outcomes in resistant cases
A cervical orthosis may supplement stretching

Operative:

Indicated when stretching fails, deformity is established, or limitation of motion exceeds 30 degrees
Ideal age: 4-5 years; permanent deformity is prevented by operating in early childhood
Unipolar release: division of the distal (clavicular/sternal) attachment - appropriate for mild deformity
Bipolar release: release at both proximal and distal ends - for moderate/severe torticollis
Endoscopic release has been described (precise division, minimal scarring) but no large series reported
Outcome measured by the Cheng and Tang Scoring System; most patients show marked improvement in neck motion, head tilt, and cosmesis

Spasmodic Torticollis (Idiopathic Cervical Dystonia)

This is a neurological form affecting adults, described in detail in Adams and Victor's Principles of Neurology (12th ed):

Most frequent form of restricted focal dystonia
Onset: early to middle adult life; more common in women (peak in 5th decade)
Begins as subtle tilting/turning of the head, worsens slowly
Muscles: SCM is most prominently affected; also levator scapulae and trapezius; posterior cervical muscles on both sides
Characteristic "sensory tricks" (gestes antagonistes): placing a hand on the chin or neck, counterpressure on the side of deviation, or contact with the back of a chair reduces the spasm - these become less effective as disease progresses
Spasms worsen on standing/walking; reduced when lying down
~15% have oral/mandibular/hand dystonia; ~10% have blepharospasm
No neuropathologic changes found at autopsy

Treatment of Spasmodic Torticollis

Botulinum toxin (first-line): Periodic injections (every 3-6 months) into affected muscles; ~90% achieve some relief. Best guided by palpation + EMG. Adverse effects: excessive weakness, local pain, dysphagia (transient). 5-10% develop neutralizing antibodies and become resistant.
Trihexyphenidyl / benztropine: Anticholinergics may give some relief but are poorly tolerated in high doses.
Deep brain stimulation (DBS): For cases refractory to medications and botulinum toxin. Targets: globus pallidus internus (GPi) or subthalamic nucleus. Preferable to older ablative procedures.
Surgical (severe/refractory): Combined sectioning of the spinal accessory nerve + first three cervical motor roots bilaterally - relief in one-third to one-half of cases for up to 6 years.

Acquired Torticollis - Key Causes to Remember

Bailey and Love's Surgery summarises: acquired torticollis may be caused by:

Inflammation/infection (e.g. retropharyngeal abscess, cervical lymphadenitis - Grisel syndrome)
Ocular problems (ocular torticollis - compensatory head tilt for diplopia or nystagmus)
Atlantoaxial rotatory subluxation - must be considered in any child with traumatic torticollis; differentiated from muscular torticollis by history, time course, and imaging
Posterior fossa tumour - a red-flag cause; must be excluded especially in children
Paroxysmal torticollis (episodic, associated with migraine in children)

Summary

Feature	Congenital (CMT)	Spasmodic (Cervical Dystonia)
Age	Infants	Adults (peak 5th decade)
Cause	SCM fibrosis/contracture	Focal dystonia (basal ganglia)
Onset	Birth / first weeks	Gradual in adulthood
SCM	Firm, fibrotic nodule	Hypertrophied, in spasm
Facial changes	Plagiocephaly if untreated	None
First-line Rx	Stretching exercises	Botulinum toxin
Surgery	SCM release (age 4-5 yr)	DBS / nerve sectioning

S Das Manual on Clinical Surgery, 13th Ed, p. 377-378
Bailey and Love's Short Practice of Surgery, 28th Ed
Campbell's Operative Orthopaedics, 15th Ed 2026, Chapter 33
Adams and Victor's Principles of Neurology, 12th Ed, p. 110-111

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