A development defect is one sternomastoid muscle or mal-position of the neck in the uterus can give rise to the deformity. The shortening of the sternomastoid is the principal causative factor. There may be an associated shortening of the scalenii, platysma, splenius or trapezius muscles. Incidence is more common in girls, and the side affected is usually left. Occasionally, it may bilateral. The affected sternomastoid may get atrophied and facial asymmetry may occur in untreated cases.
Nature of the deformity:
The head is fixed inside flexion to the same side (i.e, on the side of the affected muscle) while it is rotated to the opposite side. The shoulder on the affected side is raised.
Scoliosis with convexity to the sound side may be present in the cervical region. Facial asymmetry with smaller eye and lowering of the corners of the mouth and eye with a deviation of the nose on the affected side may be present. In rare bilateral affections, both the sternomastoid are contracted. The head is protruded forward with associated kyphosis.
The basic objectives are:
- To correct the deformity by release of the contracted soft tissues and
- To maintain the correction by suitable exercise regime; avoiding recurrence.
Early mild cases
Children with a mild degree of deformity reporting early for the treatment can be managed with physiotherapy.
The physiotherapy procedures employed are:
I. Evaluation: Careful evaluation of ROM and the degree of deformity.
II. Massage: Massage can relax the muscle preceding the stretching manoeuvres.
III. Thermo Therapy Modality: Carefully administered thermo-therapy modality induces relaxation.
IV. Passive movements: The child is placed in supine position with head beyond the edge of the table with the neck in extension by positioning a pillow under the thoracic region; Shoulders are stabilized by an assistant.
- To attain relaxation, all the movements of the cervical spine are done in a form of slow relaxed passive movements.
- This should be followed by sustained passive stretching to the affected sternomastoid. E.g. when the right sternomastoid is involved the head should be gradually bent inside flexion to the left, held there for a while and then rotated gradually to the right. Try to gain as much overcorrection as possible by applying gradual traction to gain further stretching.
- Maintenance of Correction: Once the correction is achieved. It has to be maintained by passively holding or keeping a sandbag.
- The same manoeuvre can be repeated during the subsequent visits.
- Active correction: Active correction is best achieved by assisting the child head to follow an object moved in the proper arc of correction. The bright-coloured sound producing object is ideal to attract the child attention.
- PNF: patients with neck extension can be used to an advantage with emphasis on stretch and traction
- Home treatment programme: This assumes an important role as these manipulations needs to be repeated. The mother should be trained properly for this. The best method is to put the child in prone and the teach the mother to carefully move the head towards the affected side and the child is encouraged to look back over the right shoulder.
- Positioning: Exact positioning of the head during sleep is important. The child should be made to sleep on the opposite side of the lesion and the position of head adjusted by pillow or sandbag in a maximally corrected posture during sleep. This positioning has two advantages:- First, there is natural relaxation of the muscle- Secondly, whatever correction is achieved, it is maintained for a longer period during sleep.However, the mother should intermittently check the correction.
- Older children and adults: With advancing age the deformity gets organized and does not get corrected by conservative management.
- Surgical: The sterna and the clavicular heads of sternomastoid are divided close to the origin along with the release of the tight fascia. The head is then immobilized in a plaster cast in over-corrected position for 2 to 4 weeks. Mobilization is begun as soon as the cast is removed.