Thursday, November 19, 2009

1908 Treatment of Torticollis (Wryneck)

The section of the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD on torticollis (or wryneck) is very interesting.

Torticollis, or Wryneck

Wryneck, or torticollis, is the shortening of one or more of the cervical muscles, so that the head is held in an abnormal position. There may or may not be a spasm of these muscles. The sternomastoid is the muscle most affected, although the posterior cervical muscles are usually involved to a certain extent. The condition is thought to be due to a unilateral myositis of infancy, secondary possibly to traumatism at birth, or developing as one of the lesions of congenital syphilis. As the child grows, the lack of exercise of certain muscles from the cramped position in which the head is constantly held, adds to the deformity and increases the muscular changes. If nothing is done to relieve the condition, the cervical spine will become much curved, and there will be compensatory curves in both the dorsal and lumbar spines. Even the development of the head may be affected.

Strictly speaking, cases of torticollis may be divided into acute and chronic. Usually, however, the acute symptoms will have subsided before the child is brought to the doctor.

Diagnosis –

In many cases the parent has already recognized the nature of the deformity. Inspection shows that the mastoid process on the affected side is nearer to the sternum than it should be. This means that the face is turned toward the opposite side and the chin slightly elevated, although the head may be bent toward the shoulder of the affected side. If the contraction is of long standing, the whole head will seem to have slipped over toward the unaffected side. This is due to the curvature of the neck. But the most reliable method by which to ascertain what muscles are affected is to make palpation and manipulation of the head and neck. When the head is flexed and extended, and abducted to the right and left and rotated, the difference in the muscles of the two sides of the neck is at once apparent. Such manipulation is usually not painful unless carried to an extreme degree.

A differential diagnosis between torticollis and tuberculosis of the cervical spine has sometimes to be made. In tuberculosis there is extreme tenderness, inability to move the head in any direction without pain, spasm of the cervical muscles when an attempt is made to do so. Moreover, there is a daily slight fever.

Treatment

The first treatment of acute torticollis is the treatment of the traumatism or acute myositis in which it originates. This consists in the application of heat, and the maintenance of the head in a correct position, or at least the prevention of an increase in the deformity. If the condition is considered to be rheumatic, salicylate of soda should be administered.

As soon as the pain subsides, treatment by manipulation should be commenced to correct existing deformity. The effort should be to overcorrect the deformity which exists. Therefore the face should be rotated in the opposite direction until the affected sternomastoid is tight. The chin should then be tilted downward and the head bent away from the affected shoulder. These manipulations should be made a number of times, and the treatment repeated each day until the deformity is overcome. Even then it is better for the physician to see the child once a week for a few weeks.

If the patient is an infant, manipulation described may be carried out upon the mother’s lap. If it is an older child, it should sit upright during the treatment. In either case it is an advantage if a second person holds the shoulders while the manipulations are made, so that the manipulator can make traction upon the ehad while twisting it and bending it.

During sleep the pillow should be so arranged that the position of the body will tend to correct the deformity, or at least will not tend to increase it.

In chronic cases, treatment by manipulation will succeed only if the affected muscles are still elastic; otherwise operative treatment is indicated. In slight cases, division of the sternomastoid muscle is necessary, whereas in the severer cases the trapezius splenius and other muscles will also require division.

The incision may be made parallel to the edge of the sternomastoid or parallel to the clavicle. The former leaves a slighter scar. The incision should be at least an inch long. Usually, when the most prominent bands have been divided and tension has separated their cut ends, it will be found that other deeper ones still hold the head to a lesser degree in an abnormal position. Such bands should in turn be divided until motion of the head is free. The restraining muscular bands lie a little outside the sheath of the great vessels, and the latter could be injured only by careless cutting. No deep suture is necessary. Hemorrhage should be stopped and the skin-wound entirely closed with fine black silk sutures. A firm dressing should be applied, and the head put up in an overcorrected position and held so by a plaster of Paris bandage placed around the neck, over the head, and under both arms (No 22, Chapter XXI). If there is no rise of temperature or pain, the dressing need not be changed for a week or ten days. As soon as the wound has healed, gentle passive rotation and other motions of the head should be commenced and repeated every other day for several weeks. As the time goes on the force with which this is done may be increased, and in addition the patient should practice active motion daily to correct the deformity and increase the mobility of the neck.

For more up-to-date information on torticollis, check out these links:

Torticollis –National Spasmodic Torticollis Association

Torticollis Kids

Torticollis – eMedicine article, Nov 5, 2009

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