Head tilt is a condition that causes a child to hold her head or neck in a twisted or otherwise abnormal position. She may lean her head toward one shoulder and, when lying on her stomach, always turn the same side of her face toward the mattress. This can cause her head to flatten on one side and her face to appear uneven or out of line. If not treated, head tilt may lead to permanent facial deformity or unevenness and to restricted head movement.
Most cases of head tilt are associated with a condition called torticollis (described below), although in rare instances a head tilt can be due to other causes such as hearing loss, misalignment of the eyes, reflux (a flowing back of stomach acid), a throat or lymph node infection, or, very uncommonly, a brain tumor.
Congenital Muscular Torticollis
By far the most common cause of head tilt among children under age five, this condition is the result of injury to the muscle that connects the breastbone, head, and neck (the ster-nocleidomastoid muscle). The injury may occur during birth (particularly breech and difficult first-time deliveries), but it also can occur while the baby is still in the womb. Whatever the cause, this condition usually is detected in the first six to eight weeks of life, when the pediatrician notices a small lump on the side of the baby’s neck in the area of the damaged muscle. Later the muscle contracts and causes the head to tilt to one side and look toward the opposite side.
In this condition, which is present at birth, the tilt of the neck is caused by a fusion or bony connection between two or more bones in the neck. Children with Klippel-Feil syndrome may have a short, broad neck, low hairline, and very restricted neck movement.
Torticollis Due to Injury or Inflammation
This is more likely to occur in older children, up to the age of nine or ten. This type of torticollis results from an inflammation of the throat caused by an upper respiratory infection, a sore throat, an injury, or some unknown factor. The swelling, for reasons still not known, causes the tissue surrounding the upper spine to loosen, allowing the vertebral bones to move out of normal position. When this happens, the neck muscles go into spasm, causing the head to tilt to one side.
Each type of head tilt requires a slightly different treatment. It is very important to seek such treatment early, so that the problem is corrected before it causes permanent deformity. Your pediatrician will examine your child’s neck and may order X-rays of the area in order to identify the cause of the problem. X-rays of the hip also may be ordered, as some children with congenital muscular torticollis also have an abnormality known as developmental dysplasia of the hip. If the doctor decides that the problem is muscular torticollis due to a birth-related injury to the sternocleidomastoid muscle, you will learn an exercise program to stretch the neck muscles. The doctor will show you how to gently move your child’s head in the opposite direction from the tilt. You’ll need to do this several times a day, very gradually extending the movement as the muscle stretches.
When your child sleeps, it is best to place her on her back or side, with her head positioned opposite to the direction of the tilt. She can be placed on her stomach if she allows you to turn her face away from the side of the muscle injury, and if she then keeps her head in this position while sleeping. When she is awake, position her so those things she wants to look at (windows, mobiles, pictures, and activity) are on the side away from the injury. In that way, she’ll stretch the shortened muscle while trying to see these objects. These simple strategies cure this type of head tilt in the vast majority of cases, preventing the need for later surgery. If the problem is not corrected by exercise or position change, your pediatrician will refer you to a pediatric neurologist or orthopedist. In some cases it may be necessary to lengthen the involved tendon surgically.
If your child’s head tilt is caused by something other than congenital muscular torticollis, and the X-rays show no spinal abnormality, other treatment involving rest, a special collar, traction, application of heat to the area, medication, or, rarely, surgery may be necessary. To treat Klippel-Feil syndrome, a specialist may recommend treatments ranging from physical therapy to an operation. For treating torticollis due to injury or inflammation, your doctor may recommend applying heat, as well as using massage and stretching to ease head and neck pain. Your pediatrician can refer you to a specialist for a definitive diagnosis and treatment program.