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252 Sternomastoid Tumour of Infancy and Congenital Muscular Torticollis

Sternomastoid tumour Head tilt

Physical exam:
Is there a limitation of neck rotation
indicating muscular torticollis (CMT)?
Plagiocephaly? Hemifacial hypoplasia?
Check for congenital hip dysplasia.

Tumour without torticollis; Muscular torticollis with tumour or thickening Head tilt without muscular torticollis
Will usually resolve within 6 months. of sternomastoid muscle: Needs PSE or tumour:
Look for other causes.

Age < 12 months: Age over 1 year:
1. Teach parents passive stretching Assess degree of limitation of
If tumour gets exercises. neck rotation and hemifacial Plain x-ray, CT scan, MRI
larger, is atypical, or 2. Use traditional backing and ipsilateral hypoplasia. Look for other causes.
doesn’t resolve by turning of face.
6 months, consider 3. Consider physiotherapy referral if
further investigations local expertise and cost allow it.
and biopsy.
Refer to
ophthalmologist
Good response and progress in >90% Operative intervention neurologist
of cases. 1. Age > 12months. orthopaedist
Follow up until at least 6 months of age 2. Failed after 6 months of PSE. neurosurgeon
and full range of neck rotation. 3. Neck rotation <75 degrees.
4. Palpable muscle fibrosis.
5. Progressive facial hemihypoplasia.

Consider helmet for persistent severe plagiocephaly
Postoperative physiotherapy and neck brace.

Figure 38.12: Flow chart.
Table 38.3: Evidence-based research.
Prevention
There is no primary prevention because the aetiology of sternomastoid Title Clinical determinants of the outcome of manual stretching in the
treatment of congenital muscular torticollis in infants. A prospective
tumour is unknown. Secondary and tertiary prevention strategies will study of 821 cases
identify early cases of CMT in children with SMT or breech presenta- Authors Cheng JCY, Wong MWN, Tang SP, Chen TMK, Shum SLF, Wong
tion, initiate early PSE to prevent further deformity, and avoid the need EMC
for surgery. The contracture and torticollis resulting from the sterno- Institution The Chinese University of Hong Kong and the Prince of Wales
mastoid tumour should be prevented by early identification, adequate Hospital, Hong Kong, China
physiotherapy, and good follow-up. Reference J Bone Joint Surg Am 2001; 83:679–687
Ethical Issues Problem The natural history of congenital muscular torticollis and the
outcome of different treatment modalities have been poorly
Full involvement and education of the parents in the PSE programme investigated, and the results of treatment have varied considerably.
requires time and compassionate commitment on the part of the Intervention Standardised program of manual stretching.
surgeon. Giving information that the mass and head tilt will resolve Comparison/ The study involved three groups:
spontaneously in many of the children may make mothers default from control 1. Palpable sternomastoid tumour group
regular visits due to the constraint of cost, distance to the hospital, (quality of 2. Muscular torticollis group (thickening and tightness of the
sternocleidomastoid muscle)
and long waits in the outpatient clinic. Referral to a costly supervised evidence) 3. Postural torticollis group (torticollis but no tightness or tumour).
stretching programme by the physiotherapist should be avoided if it Level 2 evidence.
will discourage the parents and lead them to default further outpatient Outcome/ Controlled manual stretching is safe and effective in the treatment
visits. The accessibility and affordability of care make follow-up chal- effect of congenital muscular torticollis when a patient is seen before
the age of 1 year. The most important factors that predict the
lenging in the African setting. outcome of manual stretching are the clinical group, the initial
deficit in rotation of the neck, and the age of the patient at
Summary presentation.
The flow chart presented in Figure 38.12 summarises the recommenda- Surgical treatment is indicated when a patient has undergone at
least 6 months of controlled manual stretching and has residual
tions of this chapter. head tilt, deficits of passive rotation, lateral bending of the neck
of >15°, a tight muscular band or tumour, and a poor outcome
Evidence-Based Research according to a special assessment chart.
Many prospective studies have been conducted to predict the outcome Historical A sternomastoid tumour was involved in 55% of the patients in
of congenital muscular torticollis, but none were randomised. The significance/ the study.
Eight percent of the sternomastoid tumour group needed surgical
study in Table 38.3, however, involves a standardised programme of comments intervention, compared to 3% and 0% in the muscular and
manual stretching. postural torticollis groups, respectively.
The worse the neck rotator deficit, the higher the need for
surgical intervention.