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INDEX

    Torticollis

    Neurological

    Last Updated Jan 19, 2022
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    By Joseph Chong, Tracy Huynh

    Context

    • Definition:
      • Torticollis is not a diagnosis. It is a sign, described as abnormal posturing of the head and neck, caused by shortening of the sternocleidomastoid.
      • Contraction of the sternocleidomastoid pulls the mastoid process ipsilaterally, while the chin rotates to the contralateral side.
    • Etiology:
      • Any injury or inflammation of cervical muscles may result in torticollis.
        • Sternocleidomastoid muscle is most commonly involved.
      • Congenital: seen in infants, more common than acquired.
        • Congenital muscular torticollis: postural, muscular, fibromatosis colli.
        • Congenital ocular, neurological, occipito-vertebral anomalies.
      • Acquired: seen in older children and adolescents.
        • Trauma, Infection, atlantoaxial rotary fixation (AARF), CNS tumours.
        • Other: ocular torticollis, benign paroxysmal torticollis, Sandifer syndrome (GERD with associated neck spasms, abnormal posturing), drugs.

    Diagnostic Process

    Figure taken from: Dayasiri K, Rao S. Fifteen-minute consultation: Evaluation of paediatric torticollis. Arch Dis Child Educ Pract Ed. 2021; 0: 1-5.

    • History:
      • Rule out life-threatening causes of torticollis:
        • Retropharyngeal abscess: acute onset, fever, drooling, odynophagia.
        • Suppurative jugular thrombophlebitis: acute onset of fever, rigors, dysphagia, unilateral neck pain. Often refractory to antibiotics.
        • C-spine trauma: MVA or fall.
        • Spinal epidural hematoma: progressively worsening neck pain following trauma, neck surgery, or history of bleeding disorders. Requires urgent neurosurgical consult.
        • CNS tumour in posterior fossa: headache, vomiting, focal neuro signs.
      • Rule out congenital muscular torticollis as a cause based on birth trauma history, physical exam looking for tight sternocleidomastoid (SCM) or mass.
      • Age of child:
        • Young children: congenital muscular torticollis, benign paroxysmal torticollis, Sandifer syndrome, spasmus nutans.
        • Older children and adolescents: acquired muscular torticollis, AARF, pharyngitis.
      • Important clinical clues:
        • History of trauma.
        • Retropharyngeal abscess: acute onset torticollis with fever, difficulty swallowing, drooling, obstruction of respiratory tract, stridor, neck swelling, limited ROM.
        • Infectious: fever, upper respiratory tract infectious symptoms.
        • Tumour: vomiting, headache, focal neurological deficits, ataxia.
        • Atlantoaxial Rotary Fixation:
          • Rare but important diagnosis.
          • Patient presents with painful torticollis.
          • Significant trauma is not necessary to cause C1-C2 subluxation; can be associated with inflammatory condition of head or neck.
        • Dystonic reaction: consider in patients taking medications with extrapyramidal side effects.
        • Sandifer syndrome: torticollis may occur after eating.
        • Benign paroxysmal torticollis: episodes of self-resolving, transient, alternating torticollis associated with vomiting, pallor, drowsiness, irritability.
    • Physical exam:
      • Head tilted to affected side and chin rotated to contralateral side (e.g., if right side is affected, head/neck is rotated to right side and chin points to the left).
      • Head and neck examination: enlarged lymph nodes.
      • Upper respiratory tract assessment: look for exudate, erythema, inflammation.
      • Eye examination: corneal light reflex, cover/uncover test.
        • Nystagmus suggests spasmus nutans.
        • Fundoscopy may reveal papilledema in Chiari malformations, ICH.
      • Neurological examination.
    • Laboratory investigations should be targeted to suspected etiology:
      • CBC
      • CRP
      • Blood cultures
      • Throat swab
      • Clotting screen
    • Imaging:
      • Ultrasound is modality of choice in newborns or infants with suspected congenital muscular torticollis.
      • X-ray (lateral and anteroposterior views) should be 1st line in older children and adolescents with post-traumatic torticollis.
      • CT of C-spine: consider in older children who present with torticollis in absence of trauma, patients with suspected retropharyngeal abscess.
      • MRI if CT findings are positive, look for associated spinal cord, ligamentous, or arterial injuries.

    Management

    • In general, self-resolving and improves in 7-10 days.
    • Supportive treatment:
      • NSAIDs
      • Physiotherapy
      • Appropriate positioning
      • Soft collar
    • Treat underlying cause:
      • Congenital muscular torticollis: positioning and handling strategies, caregiver education, physiotherapy to encourage passive stretching, refer to orthopedics.
      • Soft tissue infections in neck: IV antibiotics.
      • Trauma: immobilization of C-spine.
      • Sandifer syndrome: anti-reflux therapy.
      • Intracranial space-occupying lesions: urgent neuroimaging and referral to neurosurgery.
    • Appropriate consultations with orthopedics, ENT, ophthalmology, neurology, or neurosurgery.

    Quality Of Evidence?

    Justification

    Mostly reviews.

    Low

    Related Information

    Reference List

    1. Dayasiri K, Rao S. Fifteen-minute consultation: Evaluation of pediatric torticollis. Arch Dis Child Educ Pract Ed. 2021; 0: 1-5.


    2. Huseyin P, Canpolat M, Tumturk A, et al. Different etiologies of acquired torticollis in childhood. Childs Nerv Syst. 2014; 30: 431-40.


    3. Macis CG, Gan V, Bachur RG, et al. Acquired torticollis in children. UpToDate. Retrieved on January 4, 2022 from uptodate.com.


    4. Natarajan A, Yassa JG, Burke DP, Fernandes JA. Not all cases of neck pain with/without torticollis are benign: unusual presentations in a paediatric accident and emergency department. Emerg Med J. 2005; 22: 646-49.


    5. Pharisa C, Lutz N, Roback M, Gehri M. Neck Complaints in the Pediatric Emergency Department: A Consecutive Case Series of 170 Children. Ped Em Care. 2009; 25(12): 823-26.


    6. Starc M, Norbedo S, Tubaro M, et al. Red Flags in Torticollis: A Historical Cohort Study. Ped Em Care. 2018; 34(7): 463-66.


    7. Tomczak KK, Rosman NP. Torticollis. J Child Neur. 2012; 28(3): 365-78.


    8. Tumturk A, Ozcora GK, Bayram AK, et al. Torticollis in children: an alert symptom not to be turned away. Childs Nerv Syst. 2015; 31: 1461-70.


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