Abnormal head position or ocular torticollis. What is it? – Porto Canal interview

An abnormal or compensatory head posture (AHP) occurs when the head is deviated out of its primary and normal straight position. The medical term for an AHP is “torticollis”, deriving from the Latin words “tortus” (twisted) and “collum” (neck). In turn, a torticollis whose cause relates to an eye disease is called “ocular torticollis”.

Usually, evaluating torticollis in children requires a multidisciplinary engagement, involving paediatrics, orthopaedists, neurologists, physiatrists and physiotherapists. Consulting an ophthalmologist is additionally common and normal in order to discard ocular causes for the torticollis. On the other hand, a non-treated ocular torticollis lasting for years may lead to contractures and permanent musculoskeletal abnormalities, eventually resulting in chronic neck ache or headache.

Torticollis may involve head rotation around any of the three main axes:

• vertical axis: turning the head towards one of the primary direction sides;
• horizontal axis: chin up or down in relation to the primary position;
• anteroposterior axis: head tilted over one of the shoulders;
• a combination of two or three positions.

Congenital torticollis, meaning torticollis from birth, is more frequently due to muscular or skeletal abnormalities. In exchange, ocular torticollis rarely occurs in the first weeks of life. Trauma must always be discarded as a possible cause for any acquired abnormal head posture.

Non-Ocular Torticollis Causes

Congenital muscular torticollis is the most common torticollis type at birth. It is caused by discrete and painless muscular “fibroma” in one of the neck sides, being especially related to the sternocleidomastoid muscle. Acquired disorders include traumatic and non-traumatic causes (mainly neurological ones).

Ocular Torticollis Causes

The purpose of the ophthalmologist is to determine whether there is an eye cause for the compensatory posture. In this case, the treatment can be planned to eliminate or smooth out the problem and restore a normal head posture.

Ocular torticollis arises from disorders in the afferent visual pathway, motor ocular nerves or in the vestibular apparatus, leading to changes in the normal neurological balance for the neck muscles. AHP may arise as one of several goals:

1. optimizing visual acuity;
2. maintaining a single binocular vision (that is, annulling a double vision or diplopia);
3. centring a narrowed visual field in relation to the body;
4. Allowing fixation with one eye or the other, when the patient is unable to centre the eye due to extreme mechanical orbital problems or arising from anomalous ocular muscle enervation syndromes.

The child usually needs to be observed by a doctor for a considerable period of time to determine whether the torticollis is constant in its orientation or whether it changes, and whether it is fixed or intermittently dependent on visual tasks. Abnormal physical characteristics such as dysmorphism or nystagmus can provide clues about the aetiology. Photographic or video records from the first years of life may also help in the diagnosis.

So… what are some of the ocular pathologies causing torticollis?

1. Some types of strabismus, that is, eye misalignment;
2. Nystagmus: some patients experiencing nystagmus (rhythmic and involuntary eye movements) will acquire a head turn or tilt if the nystagmus slows down with a certain head position, thus enabling a better vision;
3. Difference in vision between the eyes: sometimes a child turns the head to place an eye with better vision closer to the target.
4. Ptosis or droopy eyelid: A child with ptosis usually elevates the chin to help the eye or eyes seeing “beneath” the droopy eyelid.
5. Refractive errors (https://www.paulofreitascosta.pt/en/erros-refrativos/)

Thus, we realize that most children adopt a head posture to improve their vision. Therefore, in general, it is important not to discourage abnormal posture in these children until the underlying problem can be corrected.

Is there any treatment?

Yes, there is. Ocular torticollis can be improved by treating the causal factor. Treatment may include surgery in the case of AHP related to strabismus, nystagmus and ptosis; or the use of eyeglasses for refractive errors or inter-ocular asymmetries of visual ability.

On December 20th 2021, Doctor Paulo Freitas da Costa was the guest at Porto Canal’s TV show program “Consultório”, where he had the chance to clarify some doubts regarding this topic! See the video in Youtube

Sources:
academia americana de oftalmologia; associação americana de oftalmologia pediátrica e estrabismo