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250 Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis

Ultrasonography has been used to classify, monitor progress, and
predict outcome of congenital muscular torticollis (Table 38.2).
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However, it is not used routinely in most centres, and treatment
decisions should be based on clinical findings. Fine needle aspiration
(FNA) cytology and open muscle biopsy are not necessary and may
x°
be misleading because the histology may look similar to a fibrous
neoplasm. These procedures should be reserved for atypical cases or
when the muscle tumour does not resolve as expected (Figure 38.9).
Management
Most cases of SMT and CMT are managed nonoperatively. Babies are
encouraged to actively look towards the affected side. In the University
Figure 38.7: Degree of hemifacial hypoplasia measured by the angle between of Ilorin Teaching Hospital, mothers are encouraged to be turning the
the plane of the eyes and mouth (x°). face of the child in the ipsilateral direction while “backing” their babies
in the traditional way (Figure 38.10). This position also helps in keep-
ing the hip flexed and abducted, preventing or reducing the chance
of a hip dislocation; this could serve as treatment for associated hip
dysplasia. This management replaces the Pavlik harness in the African
setting. For kangaroo bag (frontal child carrier bags) users, this affords
the mother the opportunity to do the massage of the neck and manual
stretching even when in transit.
Minor cases will resolve spontaneously with or without treatment,
but there is evidence that early PSEs are effective in almost all cases
when initiated prior to 3 months of age. 5,6,12,13
Passive Stretching Exercises
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The PSE technique is as follows: With the baby supine and head
suspended over the side of the examining table, one adult holds the
baby’s shoulders while the other rotates the neck to the same side as the
affected muscle. Gentle but firm pressure and some flexion are applied
at the limit of rotation to maximally stretch the muscle for 10–15 sec-
onds (Figure 38.11). This procedure is repeated 10 times, twice daily.
The keys to success are to explain the diagnosis and prognosis to the
Figure 38.8: Long-standing right sternomastoid shortening causing facial parents, demonstrate the PSE, watch them do the PSE in the clinic, and
asymmetry with secondary neck, shoulder, and back deformities. then follow-up in the clinic at 2 and 6 weeks to ensure progress. Parents
are motivated by telling them that PSE prevents the need for surgery in
Table 38.1: Differential diagnoses of torticollis. most cases. Reassure the parents that babies get used to the exercises
and do not remember the discomfort when they are older. With proper
Congenital instruction, PSE will not harm the child. The sternomastoid scar will
1. Sternomastoid tumour
2. Muscular torticollis occasionally “snap”, which may lead to some temporary swelling, but
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3. Congenital vertebral anomalies (cervical hemivertebral) this often results in an improved range of motion.
4. Klippel-Feil syndrome (atlanto-axial fusion) The PSE should be consistent and continuous until the muscle
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Trauma tumour and contracture resolve, generally within 6–8 months. PSE
1. Rotary subluxation of atlantoaxial or atlanto-occipital joints (post ear, nose, treatment is successful in more than 90% of cases when commenced
throat (ENT) surgery, such as tonsillectomy; retropharygeal abscess drainage) within the first 3 months of life. 1,6,13 Emery followed 101 children
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2. Cervical spine fracture who started treatment at a mean age of 4 months and found that the
3. Clavicular fracture
average PSE treatment duration was 4.7 months, with all but one child
Inflammatory achieving a full passive range of motion.
1. Grisel syndrome
2. Diskitis A child older than 6–8 months of age is less cooperative with the
3. Vertebral osteomyelitis PSE, and surgery is more likely to be necessary because the contracture
4. Juvenile rheumatoid arthritis is tighter and more fibrotic.
5. Cervical disc calcification A physiotherapist can be engaged to do the initial demonstration
6. Retropharyngeal abscess and follow-up of progress, especially when mothers are afraid to do
7. Cervical lymphadenitis
8. Acute lymphoblastic leukaemia the stretching or there is no response to this treatment as expected.
Physiotherapy would need to be done at least three times a week to
Neurologic 5
1. Posterior fossa tumour be effective; a professional physiotherapist service is an additional
2. Syringomyelia cost that many families would want to avoid and may lead to hospital
3. Arnold-Chiari malformation default. To prevent this, the confidence of the parents is gained by
4. Paroxysmal torticollis of infancy providing adequate information and instruction on the pathology and
5. Cerebral palsy
6. Strabismus the treatment options.
A neck brace has been used in older children as an adjunct to PSE
Others 16
1. Sandifer syndrome in chronic gastro-oesophageal reflux or after surgical treatment. If used, the neck brace should be carefully
2. Thymitis fitted and not worn at night.
3. Thyroiditis Plagiocephaly can be prevented or treated by positioning the head to
4. Postural; familial avoid persistent lying on the same side of the occiput. Measures tried