CASE SERIES: CONGENITAL MUSCULAR TORTICOLLIS TREATMENT IN INFANTS WITH A CONCURRENT DIAGNOSIS OF HEARING LOSS

Background & Purpose: In the United States, 5/100 children have a moderate to profound hearing loss (HL)1,2. 3.9-16% of newborns are diagnosed with Congenital Muscular Torticollis (CMT)3. The American Physical Therapy Association has no current recommendations for Physical Therapy (PT) treatment of CMT in infants with a concurrent diagnosis of HL2,3. Comorbidities such as visual deficits, neurological or orthopedic concerns, and increased difference in baseline ROM or muscle function are well documented as negative prognostic factors for PT treatment of CMT3,4. HL has not been studied in PT treatment of CMT. This case series examines PT episodes of care and supplemental interventions used for infants with concurrent diagnoses of CMT and HL.

Case Description: The case series included infants treated for CMT with confirmed diagnosis of HL through ABR testing. Patients with neurological, visual, and orthopedic diagnoses were excluded. 5 patients met the inclusion/exclusion criteria:
Case 1: Grade 5 left typical torticollis with mild left-sided HL (LSHL). Discharged at 16M following 5 PT visits and a TOT collar.
Case 2: Grade 1 left typical torticollis with mild right-sided HL (RSHL). Received 2 PT visits before being lost to follow up.
Case 3: Grade 1 left typical torticollis with mild-moderate bilateral HL. Discharged at 13M following 13 PT visits.
Case 4: Grade 4 left typical torticollis with mild LSHL and moderate RSHL. Discharged at 29M, with 18 PT visits, a TOT collar and botox injections. Mild gross motor delay with independent walking at 18M.
Case 5: Grade 1 right typical torticollis with profound bilateral HL. Discharged at 14M following 18 PT visits and a TOT collar. Mild gross motor delay with independent sitting at 8M; age-appropriate gross motor skills at discharge.

Outcomes: Of the 5 cases: 4 patients were discharged past 1 year old; 3 patients required supplemental intervention of a TOT collar; 1 patient received botox injections; 3 patients received more than 10 physical therapy visits. 2 patients who discharged past 1-year-old and 2 who received TOT collars were classified as Grade 1 torticollis.

Discussion: Abundant research shows that lower grade (1-3) torticollis cases resolve with relatively short episodes of care (EOC)3,5,8. However, in this case series 4 infants were discharged after 1 year old with 2/4 of the patients classified as a Grade 1 torticollis. Despite supplemental interventions being used in only 9% of infants treated for CMT, and primarily in those with greater ROM deficits6,7,8, 3/5 cases in this series required supplemental intervention through TOT collar or botox. This limited evidence suggests that concurrent diagnoses of HL and CMT could lead to extended PT EOC.
HL may be a negative prognostic factor in the PT treatment of CMT. Clinicians treating CMT in infants with HL should foster open communication with families and physicians to promote earlier diagnosis of HL and implement more efficient intervention for CMT. More evidence is needed to understand the impact of HL on PT treatment of CMT.