Torticollis

Question 1

What is torticollis?

Answer 1

Torticollis is a twisted neck, head becomes persistently turned to one side, can often be associated with painful muscle spasms.

Question 2

What are the 2 broad bands of torticollis?

Answer 2

Congenital

Acquired

Question 3

What are the 7 different bands of acquired torticollis?

Answer 3

Trauma: fracture/dislocation, Muscle spasm (“wry neck”), CNS (spinal haematoma)

Infection: Head and neck (URTI, otitis media, mastoiditis, cervical adenitis, retropharyngeal abscess), Spine (osteomyelitis, discitis, epidural abscess), CNS (meningitis)

Atlantoaxial rotary fixation: Trauma and ligamentous laxity (eg as part of underlying disorders), Pharyngeal infection (Grisel syndrome)

Inflammation: eg: Juvenile idiopathic arthritis

Neoplasm: CNS tumours, Bone tumours

Dystonic syndromes (idiopathic spasmodic torticollis, drug reactions)

Ocular dysfunction

Question 4

What are the 5 points that need to be assess on history?

Answer 4

Infective: fever, increased drooling, sore throat, dysphagia.

Time course: (Uncomplicated acute torticollis should resolve within 7 - 10 days without complication.)

Awkward position pre-symptoms, particularly if recent symptoms.

Medications associated with acute dystonic reactions e.g. metoclopramide.

Neuro: headache, strabismus, diplopia

Question 5

What are the 6 components of the examination of a child who presented with torticollis?

Answer 5

Assess for midline tenderness, general neck palpation and attempt active ROM.

Congenital muscular: palpate for sternocleidomastoid pseudotumour, head shape (plagiocephaly), hip examination.

Location of tenderness may assist with diagnosis, however deep pathology (eg: infection) may have no external signs.

Neurologic examination.

Eye examination

ENT examination including lymph nodes

Question 6

What investigations needs to be considered in a child with torticollis?

Answer 6

If the torticollis occurs in the setting of trauma it is important to follow the cervical spine injury protocol.

If considering torticollis for other reasons: Cervical Spine xray: particularly if there is cervical spine tenderness, severe pain, persistent symptoms (greater than 1 week), limitation ROM.

Ultrasound: if a mass is palpated or collection suspected. May also be helpful to confirm the fibrous SCM in congenital muscular torticollis.

CT neck and/or the brain if: Associated neurology symptoms, severe pain, bone anomaly suspected clinically or abnormal cervical xray or if there is suspicion of a retropharyngeal abscess.

Question 7

What are the 3 general measures that can be taken?

Answer 7

Analgesia or anti-inflammatory medications may be effective.

Heat packs and massage may provide symptomatic relief in cases of wry neck.

Diazepam can be effective with some cases of spasm of the SCM.

Question 8

Based on the cause of the torticollis, what are some management principles?

Answer 8

Stabilisation may be required.

Infectious cause: appropriate ABx

If a retropharyngeal or parapharyngeal abscess is suspected: Refer to ENT

Atlantoaxial rotatory fixation: Rest, use of an Aspen collar.

Injury or congenital bony cause: refer to Orthopaedics

Congenital muscular torticollis: refer to community physiotherapy for education and stretching exercises.

Severe cases persistent greater than 12 months: refer to surgery

Dystonic reactions: Benztropine