Dear Editor,
The authors wish to place on record their sincere gratitude for the interest shown in the article and greatly appreciate the observations made by the discerning reader. A detailed reply to the comments is as follows:
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a)
Congenital muscular toticollis during infancy is corrected by a regimen of stretching exercises and is associated with positive outcomes in more than 90% of cases [1]. There is no justification for a surgical approach in a child who is under one year of age [2]. Surgery is indicated when a patient has undergone at least six months of controlled manual stretching and has residual head tilt, deficits of passive rotation, lateral bending of the neck of >15 degress and a tight muscular band or tumour [3].
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b)
Unipolar release of the muscle distally, is appropriate in most cases. Bipolar release, proximally and distally, may be indicated for moderate and severe deformity and when over correction is not possible by distal tenotomy alone [4]. Since it was possible to obtain a satisfactory over correction of the deformity by unipolar distal tenotomy in this patient a proximal tenotomy was avoided, especially in view of the higher risk of injury to the Facial and the Spinal Accessory nerves associated with the latter procedure.
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c)
Post operative use of plaster cast (Minerva cast)and adjustable torticollis brace is important to maintain the head in the over corrected position, especially in children older than 2 years of age [5] and in those patients who are not highly motivated for physiotherapy [6]. The newer adjustable braces cause much less discomfort to the patient compared to plaster casts and are hence better tolerated.
References
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