Facial asymmetry in ocular torticollis
Torticollis can arise from nonocular (usually musculoskeletal) and ocular conditions. Some facial asymmetries are correlated with a history of early onset ocular torticollis supported by the presence of torticollis on reviewing childhood photographs. When present in an adult, this type of facial asymmetry with an origin of ocular torticollis should help to confirm the chronicity of the defect and prevent unnecessary neurologic evaluation in patients with an uncertain history.

Assessment of facial asymmetry consists of a patient history, physical examination, and medical imaging. Medical imaging and facial morphometry are helpful for objective diagnosis and measurement of the facial asymmetry, as well as for treatment planning. The facial asymmetry in congenital superior oblique palsy is typically manifested by mid facial hemihypoplasia on the side opposite the palsied muscle, with deviation of the nose and mouth toward the hypoplastic side.

Correcting torticollis through strabismus surgery before a critical developmental age may prevent the development of irreversible facial asymmetry. Mild facial asymmetry associated with congenital torticollis has been reported to resolve with continued growth after early surgery, but if asymmetry is severe or is not treated in the appropriate time, it might remain even with continued growth after surgery.

Facial asymmetry or plagiocephaly may result from a head tilt following the superior oblique palsy. In this condition, the midface on the side of the tilt is smaller than the other side. On the other hand, the nasal tip and septum deviate to the side of the head tilt. However, in individuals with a head turn, the nose is deviated away from the side of the head turn. Enlargement of one of the nostrils is another asymmetry which may be seen on the side of the head tilt.

Facial asymmetries that are developed in head tilts secondary to other congenital abnormalities, like congenital torticollis following the structural deformity of the SCM, are similar to the facial asymmetry in SOP.Knowledge about the manifestations of plagiocephaly is very useful for the detection of long-term torticollis.

Source: https://www.sciencedirect.com/science/article/pii/S2452232515000153