Torticollis, sometimes called wry neck or twisted neck, is the medical name for a rare condition that causes involuntary head tilting, frequently due to tightened neck muscles or another underlying condition.

Torticollis has a variety of causes. In most cases, it is a muscular problem that can easily be corrected. Other times, the condition happens because of an infection or a neurological problem. A genetic mutation can make some people more susceptible to the condition.

Whether it occurs in babies, children, or adults, torticollis can be treated. As with many conditions, the earlier torticollis is treated, the better the outcome.

Torticollis is the term used to describe a condition that arises when a person’s head leans or tilts to one side, typically due to tight muscles on one side of the neck. Babies, children, or adults can develop torticollis because of injuries, infections, neurological conditions, or medication side effects.

In healthy people, the muscles on both sides of the neck are of similar length and flexibility. However, when trauma, illness, or another cause affects the flexibility or tone of the dominant muscle on one side of the neck, it can cause the muscle to tighten. This can cause the head to turn in one direction rather than being centered and balanced.

Each type of torticollis has its own cause:

• Congenital torticollis affects a tiny percentage (0.4%) of newborns or infants. “Although the cause is not completely known, the current thought is that intrauterine positioning can lead the head to be twisted in utero,” says Yale Medicine pediatric orthopaedic spine surgeon Dominick Tuason, MD. “If the fetus remains in that position for a prolonged period of time, there can be a localized compartment syndrome phenomenon leading to ischemia [reduced or blocked blood flow/oxygen] that creates fibrosis in the sternocleidomastoid muscle. The problem can be identified either immediately after birth or a few weeks after.”

There are also some genetic mutations that can increase a baby’s risk of congenital torticollis.

• Acquired torticollis, which generally affects children, is typically caused by an injury, viral infection, or inflammation of neck muscles. In rare cases, a brain tumor can cause acquired torticollis.
• Cervical dystonia is the third type of torticollis. It typically affects adults and can be caused by a head or neck injury. Sometimes, this form of torticollis can be a side effect of medications prescribed to treat depression or other mental health conditions. It is also linked to an inherited genetic mutation.

Babies are at greater risk of congenital torticollis if they:

• Held their head at an awkward angle in utero
• Were born in the breech position
• Have Klippel-Feil syndrome
• Have Atlanto-occipital fusion
• Have genetic mutations such as GDF6, GDF3 or MEOX1

Children are at increased risk of acquired torticollis if they:

• Experienced a neck trauma or a brain injury
• Have neck burns or scars, which can restrict neck muscle movement
• Have neck muscles with too much muscle tone, leading to stiffness and movement difficulties
• Have abnormalities of the neck vertebrae
• Have juvenile idiopathic arthritis
• Have a retropharyngeal abscess
• Have Lemierre syndrome
• Have Chiari malformation

Adults are at greater risk of cervical dystonia if they:

• Experienced a neck trauma
• Have a brain injury
• Have neck burns or scars, which can restrict neck muscle movement
• Have neck muscles with too much muscle tone, leading to stiffness and movement difficulties
• Have a rare genetic mutation, such as CIZ1, ANO3 or GNAL
• Have arthritis
• Have a herniated disk

Torticollis may be recognizable because it affects a person’s head positioning. Symptoms include:

• Limited range of motion of the head and neck
• Neck stiffness and pain
• Having one shoulder higher than the other
• Inflamed or swollen neck muscles
• Numbness or tingling in the neck
• Head or neck tremors
• Headaches
• Vision changes
• Nausea or vomiting
• Fever
• Balance problems
• Changes in gait
• Changes in bladder or bowel habits

In babies, the primary symptom is the characteristic “wry neck,” or twisted neck, appearance. However, it is typically not painful.

Doctors can diagnose torticollis after learning about a patient’s medical history, performing a physical exam, and ordering diagnostic tests.

If the patient is a baby, doctors will ask the parents about the pregnancy and birth. For children and adults, it’s important for doctors to know when their symptoms began and if the condition is painful.

For infants, doctors will physically examine the baby’s head and neck, looking for a small, palpable, painless lump on the neck muscle. The baby’s range of neck motion will be measured. Doctors will also look for a flattened spot on the baby’s head or face, which can arise because the baby only turns their head one way while sleeping, putting pressure on the skull or face.

If acquired torticollis in a child or cervical dysplasia in an adult is suspected, the patient’s range of motion in their head and neck will be assessed. In addition, a neurological exam will be performed to determine if the patient has difficulty with movement, gait, or balance.

The following imaging tests can also be used to diagnose torticollis:

• Ultrasound, to check for the presence of a mass on the neck muscle in babies
• X-ray or CT scan, to look for damage to tissue or neck vertebrae
• MRI, to rule out other conditions
• Blood tests, to check for genetic mutations
  

Treatments for torticollis are different, depending on the cause of the condition.

• Congenital torticollis:
• Physical therapy. Babies with congenital torticollis may find symptom relief from stretching exercises that a doctor or physical therapist can show parents how to perform at home. The exercises are intended to stretch out the tight neck muscle so that the head rests in a neutral position rather than at an angle. “Tummy time”—putting a baby on their stomach to strengthen the neck muscles—can also help. Parents will also learn how to minimize the risk of flat head syndrome, which can occur when a baby frequently lies down with their head turned in the same direction. Additionally, some babies might benefit from physical therapy or from wearing a collar (during waking hours) that keeps the head and neck in a neutral position.
• Botulinum toxin (Botox) injections. If physical therapy and stretching aren’t effective treatments, some babies can receive Botulinum toxin injections, which can relax the tight neck muscle and resolve the problem.
• Surgery. In less than 10% of cases, surgery is needed to help lengthen the tight neck muscle or correct a vertebral problem. This surgery usually occurs when the child is 6 years old.
• Acquired torticollis. Non-steroidal anti-inflammatory drugs (NSAIDs) and a neck collar can help to treat the condition. In some cases, children will also benefit from a muscle relaxant.
• Cervical dystonia. Several treatment options can be used to help adults with cervical dystonia:
  • Physical therapy
  • A neck collar
  • Heat therapy
  • Neck traction
  • Treating an underlying illness or injury that caused torticollis
  • Deep brain stimulation
  • Surgery, if other treatments aren’t helpful

Doctors may prescribe medication to relieve pain or muscle spasms, including:

• NSAIDs
• Benzodiazepines, a class of anti-anxiety medication
• Muscle relaxants
• Cholesterol-lowering medication
• Botulinum toxin injections

Torticollis is a treatable condition that resolves in many patients with stretching, physical therapy, or medication. Between 90% and 95% of babies who receive early treatment improve during their first year.

Babies and children may respond to treatment more readily than adults, especially those treated during the first three months of life.