A case of missed ocular torticollis

Torticollis is defined by head tilt toward the contractured muscle and chin rotation to the opposite direction, and can lead to secondary problems such as plagiocephaly, scoliosis, delayed cognitive development and impaired balance [Cooperman, 1997]. Torticollises are a common cause of referral to rehabilitation clinics in the pediatric setting. The etiologies of torticollis may be orthopedic, neurologic or ocular. Congenital muscular torticollis due to sternocleidomastoid contracture is the most common type in infants and may be treated with conservative treatment such as muscle stretching. Surgery is recommended in congenital muscular torticollis if conservative treatment is ineffective or if it results in progressive maxillofacial asymmetry [Suhr and Oledzka, 2015]. Other causes are ocular torticollis due to ocular muscle weakness, Sandifer’s syndrome due to gastroesophageal reflux, neural axis abnormalities and benign paroxysmal torticollis. Ocular torticollis usually occurs due to different ophthalmic conditions, including paralytic and restrictive disorders of ocular movement, nystagmus and defects of the visual field [Herman, 2006]. Here we report a missed ocular torticollis in a girl with presumed congenital muscular torticollis. Case presentation A 5-year-old girl with presumed congenital muscular torticollis underwent left sternocleidomastoid muscle-release surgery. As the patient’s symptoms were not improved after surgery, she was referred to a physical medicine and rehabilitation clinic for further physical treatment. The child had left-side head tilt and chin rotation to the right side with normal passive range of motion. There was no facial asymmetry. Musculoskeletal and neurologic evaluations and cervical vertebrae imaging were normal and there was no evidence of muscular mass or shortening in neck muscles. The patient underwent several sessions of physiotherapy, but despite the normal range of motion, head tilt was not corrected. For further evaluations, she was referred to an ophthalmologist. In ocular motility examination, there was right hypertropia and overaction of the right inferior oblique muscle with underaction of the right superior oblique muscle. Visual acuity was 10 out of 10. The patient was diagnosed with congenital right superior oblique palsy and underwent right inferior oblique muscle weakening. In follow-up examination 1 week after surgery, hypertropia was eliminated and head tilt was corrected.