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CHAPTER 38

Sternomastoid Tumour of Infancy and

Congenital Muscular Torticollis

Lukman O. Abdur-Rahman
Brian H. Cameron

Introduction to poor neck control in infants before this age (Figure 38.2). Some of
Sternomastoid tumour (SMT) of infancy is usually associated with con- the cases are first noticed by grandmothers while doing the traditional
genital muscular torticollis (CMT); these will be discussed together in body massage for the babies.
this chapter. The term “tumour” is a misnomer because it is a congenital Physical Examination
fibrotic process; it also is referred to as congenital fibromatosis coli. A sternomastoid tumour is defined by the presence of a palpable,
The terms “torticollis” and “wryneck” actually describe the tilting and hard, spindle-shaped, painless, 1–3 cm diameter swelling within the
rotation of the head and neck that results from the contracture of the substance of the sternocleidomastoid muscle, usually located in the
sternocleidomastoid muscle. The torticollis, when untreated, results in lower and middle third of the muscle. The mass may be confused with
plagiocephaly, hemifacial hypoplasia, and body distortion. The key to a lymph node or neoplasm, which is far less likely at this age.
preventing deformity is early diagnosis and passive stretching exercises Children presenting with CMT should have the entire length of the
(PSEs) of the affected muscle, with only 5% of cases needing surgical sternomastoid muscle palpated to determine whether the swelling or area
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intervention in a large prospective series.
Demography
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The prevalence of SMT and CMT in Africa is unknown. At the
University of Ilorin Teaching Hospital in Nigeria over a period of 10
years (1999–2008), only 15 cases presented at the outpatient clinic
and only one had surgical intervention at 10 months of age because of
severe torticollis. CMT is reported to occur in 0.3–2% of all births, with
a slight male preponderance. The right side is affected in 60% of the
cases, and 2–8% are bilateral.
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Aetiology
The sternocleidomastoid muscle is enveloped by the deep cervical
fascia as it attaches to the clavicle, manubrium, and mastoid process.
The aetiology of SMT is unknown, but the current theory is that it
results from abnormal intrauterine positioning, leading to intramuscular
compartment syndrome and ischaemic muscle injury with subsequent
fibrosis and contracture of the sternomastoid muscle. Muscle biopsy Figure 38.1: Sternomastoid tumour on the right side, with the child’s head
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shows replacement of muscle bundles with a mass of maturing fibrous turned away from the affected side.
tissue—evidence that the pathology may begin prenatally.
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Contracture of the sternomastoid muscle on one side causes the head
and neck to tilt (flex) to the ipsilateral side and the face to turn toward
the contralateral side (Figure 38.1).
If untreated, the sternomastoid tumour naturally resolves completely
in 50–70% of the cases by 6 months of age, with muscle shortening
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persisting in 5–7% after 1 year. Hence, late presentations are usually
accompanied by fibrotic and shortened sternocleidomastoid muscle
from a missed or unrecognised sternomastoid tumour.
Clinical Presentation
History
Infants present with either a lump in the neck, or with a head tilt that
is not correctable by repositioning. SMT is usually absent at birth and
presents between 3 weeks to 3 months of age. There is a high incidence
of breech presentation or assisted delivery. It is important to reassure
the parents that the obstetric difficulty is thought to be the result rather
than cause of the shortened sternomastoid muscle.
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Many parents present their children after 3 months of age in the
African setting because they presume the abnormal position to be due
Figure 38.2: Note the posture of the older baby with left sternomastoid tumour.