Differential Diagnosis and Management of Abnormal Posture of the Head and Neck

Shin-Young Yim; Il Yung Lee; Myong Chul Park; Jang-Hee Kim

doi:10.5124/jkma.2009.52.7.705

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Yim, Lee, Park, and Kim: Differential Diagnosis and Management of Abnormal Posture of the Head and Neck

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J Korean Med Assoc 2009;52(7):705-718.

Published online: 10 January 2009

DOI: https://doi.org/10.5124/jkma.2009.52.7.705

Differential Diagnosis and Management of Abnormal Posture of the Head and Neck

Shin-Young Yim, MD, Il Yung Lee, MD, Myong Chul Park, MD, Jang-Hee Kim, MD

Department of Physical Medicine and Rehabilitation/Ajou Torticollis Clinic, Ajou University School of Medicine E – mail: syyim@ajou.ac.kr, iylee@ajou.ac.kr

Department of Plastic and Reconstructive Surgery/Ajou Torticollis Clinic, Ajou University School of Medicine E – mail: mpark@ajou.ac.kr

Department of Pathology/Ajou Torticollis Clinic, Ajou University School of Medicine E – mail: mrkjhk@yahoo.co.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Abnormal posture of the head and neck can happen to anybody from neonates to adults, which requires appropriate interventions according to etiologies. Congenital muscular torticollis is the most common cause of abnormal posture of the head and neck in infancy, where early intervention as soon as possible is critical for better therapeutic outcome. Childhood laterocollis is heterogeneous condition, which needs etiological diagnosis for the proper management. Cervical dystonia is the most common form of focal dystonia and an overview on clinical presentations and therapeutic options including chemodenervation with botulinum toxin injection was provided. Abnormal posture of the head and neck of acute onset could be a sign of serious conditions and needs differential diagnosis.

Keywords: Congenital muscular torticollis, Cervical dystonia, Acute torticollis, Laterocollis, Superior oblique palsy

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Figure 1.

Abnormal posture of the head and neck. (A) Left torticollis, (B) Right laterocollis, (C) Anterocollis, (D) Retrocollis.

Figure 2.

A 10 month-old girl who has right congenital muscular torticollis. (A) Unilateral palpable neck mass of muscle-consistency on right sternocleidomastoid muscle. (B) and (C) Neck MRI findings showing large mass of right sternocleidomastoid muscle.

Figure 3.

Children who have left congenital muscular torticollis which have thick and short left sternocleidomastoid muscle, ending up with right torticollis and left laterocollis.

Figure 4.

(A) Relations between the sternocleidomastoid muscle (SCM) and the internal branch of the superior laryngeal nerve (ibSLN). (B) Relations between the ibSLN and the other anatomic structures. ECA external carotid artery, SLA superior laryngeal artery Adapted from Kiray A, Naderi S, Ergur?, Korman E. Surgical anatomy of the internal branch of the superior laryngeal nerve. Eur Spine J 2006; 15: 1320–1325 with kind permission of Springer Science + Business Media.

Figure 5.

Three-dimensional CT showing left plagiocephaly associated with left congenital muscular torticollis.

Figure 6.

A diagram showing spontaneous compensation for torticollis by (A) elevation of the shoulder on the affected side or by (B) production of cervical scoliosis with two curves.

Figure 7.

The ultrasonographic findings of the sternocleidomastoid muscle for the children who had congenital muscular torticollis (CMT).

Figure 8.

Histologic findings of the sternocleidomastoid muscle with congenital muscular torticollis. (A) Diffuse fibroblastic proliferation with fibrosis and accompanying atrophic muscle fibers. H&E;x100. (B) Irregular arrangement of fibrous trabeculae, mature adipose cells and muscle fibers. H&E;x100.

Figure 9.

Ajou therapeutic protocol for children with congenital muscular torticollis at the age of 3 months or younger.

Figure 10.

The boys who show (A) right laterocollis and (B) left laterocollis.

Figure 11.

Differential diagnosis of abnormal posture of the head and neck in children.

Figure 12.

The biosynthetic pathway of tetrahydrobiopterin and dopa from guanosine triphosphate (GTP). GCH 1:GTP cyclohydrolase I, Phe: phenylalanine, Try: tyrosine.

Table 1.

Doses and muscles to inject as first line therapy, as well as maximum does, depending on the type of cervical dystonia

Type of cervical dystonia	Muscles to be injected	Dose at the first injection		Maximum dose
Type of cervical dystonia	Muscles to be injected	Botox^®	Dysport^®	Botox^®	Dysport^®
Torticollis	Ipsilateral splenius capitis and sternocleidomastoid	50∼80	150∼240	150	450
Laterocollis	Trapezius and/or iIpsilateral levator scapulae and/or sternocleidomastoid and/or scalene	25∼30	75∼90	60	180
		30∼60	90∼180	70∼80	210∼240
		30∼60	90∼180	60∼70	180∼210
		30∼40	90∼120	60	180
		30∼40	90∼120	50	150
Retrocollis	Bilateral splenius capitis	70∼100/70∼100	210∼300/210∼300	150/150	450/450
Anterocollis	Bilateral sternocleidomastoid	25∼30/25∼30	75∼90/75∼90	40/40	120/120

Adapted from Ranoux D. Cervical dystonia. In: Ranoux D, Gury C, eds. Practical handbook on botulinum toxin. Marseile, France: Solal, 2007: 35–50 (32).

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