|Year : 2016 | Volume
| Issue : 2 | Page : 57-60
The fate of facial asymmetry after surgery for "muscular torticollis" in early childhood
Asst. Professor of Paediatric Surgery, Ankur Paed Surgical Clinic, Kolhapur; SJKC Trust's Paediatric Surgery Centre and Postgraduate Institute, Sangli, Maharashtra, India
|Date of Web Publication||18-Feb-2016|
Ankur Paed Surgical Clinic' 1666, 'E Ward' 10th Lane Rajarampuri, Kolhapur - 416 001, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims and Objectives: To study wheather the facial features return to normal after surgery for muscular torticollis done in early childhood. Materials and Methods: This is a long-term study of the fate of facial asymmetry in four children who have undergone operation for muscular torticollis in early childhood. All the patients presented late, i.e., after the age of 4 years with a scarred sternomastoid and plagiocephaly, so conservative management with physiotherapy was not considered. All the patients had an x-ray of cervical spine and eye and dental checkup before making a diagnosis of muscular torticollis. Preoperative photograph of the patient's face was taken to counsel the parents about the secondary effect of short sternomastoid on facial features and the need for surgery. After division of sternomastoid muscle and release of cervical fascia when indicated, the head was maintained in a hyperextended position supported by sand bags for three days. Gradual physiotherapy was then started followed by wearing of a Minerva collar that the child wore for a maximum period of time in 24 h. Physiotherapy was continued three times a day till the range of movements of the head returned to normal. During the follow-up, serial photographs were taken to note the changes in the facial features. Results: In all four patients, the asymmetry of the face got corrected and the facial features returned to normal. Conclusion: Most of the deformity of facial asymmetry gets corrected in the first two years after surgery. By adolescence, the face returns to normal.
Keywords: Asymmetry of the face, muscular torticollis, plagiocephaly, sternomastoid tumor
|How to cite this article:|
Kittur D. The fate of facial asymmetry after surgery for "muscular torticollis" in early childhood. J Indian Assoc Pediatr Surg 2016;21:57-60
|How to cite this URL:|
Kittur D. The fate of facial asymmetry after surgery for "muscular torticollis" in early childhood. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2019 Sep 16];21:57-60. Available from: http://www.jiaps.com/text.asp?2016/21/2/57/176936
Torticollis detected soon after birth needs to be investigated and treated promptly.  Cervical vertebral deformity and ocular causes need to be ruled out. With regular physiotherapy, a sternomastoid tumor regresses and the development of craniofacial deformity such as plagiocephaly and asymmetry of the face that can affect the body image of the child later in life can be prevented. , It also saves the child of an operation. As the infant grows it resents muscular stretching and passive movements during physiotherapy and often cries. This is one of the causes of dropouts in the regular physiotherapy schedule. By the age of 3 years, the patients do not respond to physiotherapy. 
Untreated patients or in whom physiotherapy has failed need surgery. Along with division of the sternomastoid muscle, the scarred cervical fascia may have to be released too.  During counseling, the parents' main worry is whether the face will return to normal after surgery. They need to be assured from time to time that patience is needed along with gradual and regular physiotherapy. The facial features take years to return to normal. 
| Materials and methods|| |
In the period between 1981 and 2014, five patients who presented to me after the age of 4 years had surgery for muscular torticollis. Three of these patients were born by lower segment Cesarian section (LSCS) for breech presentation. One of them reported to have a sternomastoid tumor after birth. All the patients had contracture of the sternomastoid muscle, plagiocephaly, and asymmetry of the face at presentation. Two of them were advised physiotherapy during infancy but did not follow it meticulously. One of the five patients who were lost for follow-up has been excluded from the study.
During clinical examination, obvious cervical vertebral deformity was ruled out. The active range of movements of the head on either side were noted. On palpation, the scarring of the sternomastoid muscle and the fascia around was noted in both the neutral position and hyperextension of the head. A clinical photograph of the face was then taken with the patient sitting up in the natural attitude. The patients then had a routine hemogram, an ophthalmic consultation, and x-ray of the neck to rule out ocular problems and cervical vertebral deformity. During the follow-up as they grew up, serial photographs were taken to study the changes in the facial features.
The parents were then counseled about the deformity in detail and the need for surgery. The following points were stressed:
Normal anatomy and function of the sternomastoid muscles.
Scarring of the affected sternomastoid muscle and the restrictions in head movements were demonstrated.
A photograph of a normal child was shown to impress them that both halves of the face are usually almost identical. This was demonstrated by drawing lines over the fixed landmarks of the face, i.e., orbit, base of alae of nose and lips, etc. where all these lines are almost parallel.
Their child's photograph was then shown and compared with the normal. Measurements were taken between similar lines drawn to show that they were not parallel [Figure 1]. This convinced the parents about asymmetry of the face. The need for division of the scarred sternomastoid muscle, the schedule of gradual physiotherapy, and wearing of a Minerva collar by the child until the head movements return to normal was then explained to them.
|Figure 1: The figure shows serial photographs of one patient wherein surgery was done at presentation (4.5 years) and gradual correction of facial asymmetry was done subsequently. The lines drawn help to quantify the asymmetry and its correction in the recent photograph.|
Click here to view
A nasal endotracheal tube was preferred. A bolster under the shoulder allowed hyperextension of the head draped in such a way so as to allow full rotation of the head during surgery. I prefer to divide the sternomastoid muscle above the division into the two heads. The cervical fascia was then palpated while the assistant rotated the head in all directions. This helped me to assess the extent of scarring that can extend to the border of the trapezius muscle. The scarred fascia was released in one patient. The wound was closed with subcuticular suture of 5.0 vicryl.
For three days, the patient's head was kept in a similar hyperextended position as operation supported by a sandbag on either side to prevent painful rotation.
On the fourth day, physiotherapy was started first with side-to-side rotation that was less painful than the hyperextension of the head that followed later. On the fifth day, the patient was allowed to sit up and do the physiotherapy. On the seventh day, the child was given a custom-made Minerva collar that kept the head in a slightly extended position. The patient was discharged on the eighth day and was asked to use the collar for maximum time possible in the day and night for a period of 6 months or till the movements of the head returned to normal.
In the first month, the patient attended the outpatient department every week to ensure that the physiotherapy is being followed meticulously. At follow-up visits, a range of movements of the head were assessed to confirm that they were improving. The child was then seen every 3 months. A photograph of the face was taken and compared with the preoperative photograph.
| Results|| |
In all four patients, the asymmetry of the face got corrected and the facial features returned to normal [Figure 1].
| Discussion|| |
The plagiocephaly and asymmetry of the face is due to the scarred sternomastoid. This seems to be in accordance with the theory of functional matrix, i.e., form follows function.  Quantification of the asymmetry is done in the preoperative photograph [Figure 1]. This helps to convince the patient's parents about the need for surgery. Later, as the face grows the features return to normal, the reduction in measures of the asymmetry is to be interpreted taking into account the facial growth. It was interesting to note that in all the four patients the occlusion was well maintained though the occlusal level was oblique. The temporomandibular joints were clinically normal.
Most of the patients of muscular torticollis detected in the neonatal period can be successfully treated by physiotherapy. In my experience, even a large sternomastoid tumor regresses within few months with physiotherapy. This has been the experience of other as well.  As the infant grows, it resents muscular stretching and passive movements during the physiotherapy and often cries. This is one of the important causes of dropouts in the regular physiotherapy. The compliance to physiotherapy is usually unsatisfactory after the age of 1 year.  The infant develops progressive plagiocephaly and asymmetry of the face along with restriction of head rotation.
All our patients in this study presented after the age of 4 years and so physiotherapy was not considered. The parents' main complaint and concern was the obvious deformity of the face and they wanted to know if it would return to normal after surgery. Showing the progressive changes in the face of another patient impressed the parents and they willingly opted for surgery. It is important to stress upon the need for regular physiotherapy and that the facial changes are gradual and one needs to have patience.
Three patients always complained of severe sweating in the neck region while using the Minerva collar. Especially in the summer, the skin of the neck needs to be kept dry with the use of prickly heat powder. The modern collars have vents for proper aeration of the skin and soft padded borders to prevent abrasions to the chin and shoulder.
The reports in literature regarding outcome of surgery are not very encouraging.  It was interesting to note in our patients that gross changes in the facial features occurred within the first 2 years after surgery. Later, the changes were slow and by adolescence the facial features had returned to normal.
| Conclusion|| |
The long-term outcome of surgery for torticollis in early childhood supported by regular physiotherapy is good. The asymmetry of the face gets fully corrected by adolescence. Both the parents and the clinicians need to be patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Aarnivala HE, Valkama AM, Pirttiniemi PM. Cranial shape, size and cervical motion in normal newborns. Early Hum Dev 2014;90:425-30.
Krugman ME, Canalis R, Conrad HR. The sternomastoid "tumor" of infancy. J Otolaryngol 1976;5:523-9.
Moss ML. The functional matrix hypothesis revisited. 1. The role of mechanotransduction. Am J Orthod Dentofacial Orthop 1997;112:8-11.
Masłoñ A, Lebiedziñski R, Domzalski M, Snyder M, Grzegorzewski A. Facial asymmetry in children with congenital muscular torticollis after surgical treatment. Hir Narzadow Ruchu Ortop Pol 2009;74:31-4.
Cheng JC, Tang SP. Outcome of surgical treatment of congenital muscular torticollis. Clin Orthop Relat Res 1999;190-200.
Chate RA. Facial scoliosis from sternocleidomastoid torticollis: Long-term postoperative evaluation. Br J Oral Maxillofac Surg 2005;43:428-34.
Canale ST, Griffin DW, Hubbard CN. Congenital muscular torticollis. A long-term follow-up. J Bone Joint Surg Am 1982;64:810-6.