Congenital Neck Tilt (Torticollis)

In medical terminology, congenital neck tilt, also called torticollis, is the third most common congenital deformity after congenital hip dislocation and pes equinovarus deformity. Its incidence ranges widely from about 0.3% to 2%, and it is more commonly seen on the right side. Although the exact cause of torticollis remains controversial, the most widely accepted theories involve intrauterine compression and vascular events.

What is Congenital Neck Tilt?
Congenital neck tilt occurs due to a mild contraction of the sternocleidomastoid (SCM) muscle, as if the muscle is continuously contracted, leading to deformity on the affected side of the baby’s face and neck.

What Causes Congenital Neck Tilt?
While the exact cause is not fully determined, some suggested factors include:

• Compression within the uterus,
• Vascular events, likely resulting from birth trauma causing impaired blood supply to the muscle,
• Compartment syndrome,
• Primary disorder of the SCM muscle.

Although 30-60% of torticollis patients have a history of difficult birth, torticollis can also be seen in babies delivered by cesarean section.

What Are the Symptoms of Congenital Neck Tilt?
At first examination, torticollis is usually diagnosed by the typical head posture. Because the SCM muscle on the affected side is shortened, the neck tilts toward the affected side while the face and chin turn toward the opposite side. The half of the face on the affected side appears smaller.

How is Congenital Neck Tilt Diagnosed?
A detailed head and neck examination should be performed in all newborns for early diagnosis. The SCM muscle should be examined manually for masses, hematomas, or other abnormalities.

The initial physical examination by the physician is usually sufficient for diagnosis. However, to support the diagnosis and exclude other possible causes of torticollis, some radiological tests may be required. The most commonly preferred imaging method is ultrasound.

If bone fracture is suspected, plain cervical X-rays may be requested.

To assess muscle thickening or fibrosis, MRI is a good choice.

If muscle or nerve denervation is suspected or detected, electromyography (EMG) should be performed for differential diagnosis.

How Should Congenital Neck Tilt Be Treated?
Treatment can be conservative or surgical. The goals of treatment are:

• To prevent shortening of the SCM muscle,
• To keep the head in a symmetrical position,
• To prevent future bone deformities.

The most important aspect of treatment is educating the family. Patience is necessary, and the exercises and movements should be demonstrated one by one. If any restriction is observed in neck rotation, physical therapy should start as early as possible. Conservative treatment should be initiated for all patients.

The treatment stages include:

Positioning: This is the most important part of conservative treatment and must be applied by the family with proper training. The baby’s head should be positioned to the opposite side of the shortened SCM muscle. Positioning should encourage the baby to respond to auditory stimuli and move their head independently using visual and sound cues. When carrying the baby, one hand should support under the neck at forearm level.

Range of Motion Exercises: Slow, gentle, and careful movements including neck flexion, extension, lateral bending, and rotation should be applied. In babies younger than 6 months, complete adherence to the exercise program can yield excellent results, with success rates ranging from 76% to 97%. The program should last at least 1 year, and the frequency of exercises should be determined by therapists.

Neck Stretching Exercises: These are applied similarly. Initially, stretching may be stiff but will soften over time. Duration and frequency should follow the therapist’s recommendations.

If the neck tilt remains more than 10 degrees in babies older than 4 months despite regular home exercise programs, a tubular torticollis orthosis (torticollis pillow) must be used.

Surgical treatment is recommended for patients who develop facial asymmetry, do not benefit from 6-12 months of conservative treatment, and have more than 15 degrees of lateral cervical flexion limitation and more than 30 degrees of rotation limitation. The ideal age for surgery is between 1 and 4 years old