Have you ever seen a toodler or a child with a recurrent twisted head? What could be causing this abnormal head position? How can you tell if it is postural or visual?
Torticollis is an abnormal head posture caused by ocular or non-ocular factors. Ocular torticollis (OT) is a compensatory head posture adopted to prevent double vision or cushion nystagmus. The abnormal ocular posture of the head (PAA) or torticollis is a frequent sign in pediatric pathology. The incidence is 5.6% in ophthalmological practice and 3.19% in pediatric ophthalmological practice. The abnormal head posture is adopted to improve visual acuity, maintain single binocular vision, center the residual visual field with the body or for cosmetic reasons. The behavior of patients with ocular torticollis is different from those whose torticollis is not ocular, although research is still lacking.
In view of the anomalous position of the head after 6 months, it should be possible to pass the 5-question questionnaire developed by the Development of a questionnaire to identify ocular torticollis study. Questionnaire to differentiate between ocular and postural torticollis (neurological and orthopedic diseases were excluded from the study).
5 key questions to ask parents
- Is the direction of your child’s head tilt always the same?
- Is the inclination worse when your child is looking at an object?
- When you indicate the tilt of the head, can your child straighten the position of the head by himself?
- Does your child blink with one or both eyes intermittently?
- Do your child’s eyes sometimes seem out of alignment with the object of focus?
Each affirmative answer in this questionnaire may increase the need for visual assessment.
The questionnaire based on behavioral characteristics can help detect and determine the need for visual evaluation of both the pathology, the competence of the ophthalmologist, and the functional evaluation of the optician-optometrist competence in patients with torticollis.
Subjects with ocular and non-ocular torticollis show similar turning frequencies. Furthermore, the associated restricted head rotation does not appear to sufficiently exclude an ocular cause, as shortening of the neck muscles can occur as a consequence of prolonged asymmetry in ocular torticollis.
The most common ocular causes of head tilt in children are congenital nystagmus, superior oblique paresis, dissociated vertical deviation, Brown syndrome, refractive errors. Abnormal up or down head postures are most commonly caused by “A” and “V” pattern strabismus, eyelid ptosis, nystagmus, refractive errors. Torticollis is not a diagnosis, but it is a sign of an underlying disease.
Interdisciplinary collaboration between vision professionals (ophthalmologists and opticians-optometrists) professionals linked to pediatrics (pediatricians, otolaryngologists, neurologists, developmental expert physiotherapists) and education (teachers, child educators, early care professionals) is mandatory to detect and establish the etiology of the abnormal head position.
The Vision in Development and Learning course for the PIMT concept aims to unify the different perspectives of professionals in contact with early childhood. You can sign up here.
References:
- Yoon JA, Choi H, Shin YB, Jeon H. Development of a questionnaire to identify ocular torticollis. Eur J Pediatr. 2021 Feb;180(2):561-567. doi: 10.1007/s00431-020-03813-2. Epub 2020 Sep 26. PMID: 32979091.
- Nucci P, Kushner BJ, Serafino M, Orzalesi N. A multi-disciplinary study of the ocular, orthopedic, and neurologic causes of abnormal head postures in children. Am J Ophthalmol. 2005 Jul;140(1):65-8. doi: 10.1016/j.ajo.2005.01.037. PMID: 16038652
- Hofsli M, Vinding T, Sandfeld L, Hesgaard HB. [Ocular torticollis is a diagnostic and surgical challenge]. Ugeskr Laeger. 2019 Sep 23;181(39):V12180886. Danish. PMID: 31543099.
- Tomaç S, Kalayci D, Hasiripi H. Synostotic plagiocephaly causing pseudoparalysis of the superior oblique and ocular torticollis: report of a case with unique sensory findings. Binocul Vis Strabismus Q. 1998;13(4):267-72. PMID: 9852441.
- Boricean ID, Bărar A. Understanding ocular torticollis in children. Oftalmologia. 2011;55(1):10-26. PMID: 21774381.
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