Acquired Torticollis


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Cervical Spine Injury  

    Febrile Child

    Key Points

    1. If torticollis occurs in setting of trauma, manage as Cervical Spine Assessment
      1. If the child has signs of fever, infection or abnormal neurology, appropriate imaging should be performed to establish a cause. 
      2. Most children will have a muscular torticollis and can be managed with simple analgesia.

      Background 

      Torticollis (twisted neck), is a non-specific sign with a large spectrum of aetiologies.

      Causes of acquired torticollis:

      • Muscle spasm (Wry neck)
      • Trauma: Fracture/dislocation, Spinal haematoma
      • Atlantoaxial rotary subluxation/fixation
      • Infection: Head and neck, spine, CNS or upper lobe chest
      • Inflammation: Juvenile idiopathic arthritis
      • Neoplasm: CNS (posterior fossa) and Bone tumours
      • Dystonic syndromes (idiopathic spasmodic torticollis, drug reactions)
      • Ocular dysfunction
      • Benign Paroxysmal Torticollis  

      Assessment

      Red flag features in Red

      History

      • Time course: Uncomplicated acute torticollis should resolve within 7-10 days
      • History of awkward position e.g. recent flight, different sleeping arrangement
      • History of trauma, even minor
      • Infective symptoms: fever (see febrile child), increased drooling, sore throat, dysphagia
      • Neurological symptoms: headache, strabismus, diplopia, photophobia, ataxia 
      • Medications associated with acute dystonic reactions e.g. metoclopramide

      Examination

      • Midline tenderness, general neck palpation and attempt active ROM 
      • Location of tenderness may assist with diagnosis, however deep pathology (e.g. infection) may have no external signs
      • Neurologic examination
      • Ophthalmologic examination
      • ENT examination including lymph nodes 
      • Chest examination 

      Management

      Investigations 

      Consider:

      • Cervical Spine xray: particularly if there is cervical spine tenderness, severe pain, persistent symptoms (≥1 week) or the child has a risk of atlantoaxial instability (e.g. Down syndrome, Morquio syndrome, Larsen syndrome, Marfan syndrome). See Cervical Spine Assessment
      • CT neck and/or the brain if:
        • Associated neurology symptoms
        • Severe pain not alleviated by analgesia or relaxants
        • Bone anomaly suspected clinically or abnormal cervical xray
        • There is suspicion of a retropharyngeal abscess

      Depending on the presentation, consultation with, General Medicine, Orthopaedics, ENT, Ophthalmology or Neurology will help with decisions about imaging. 

      Treatment

      For most children, heat pack, massage and basic analgesia is appropriate treatment.

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

      Management depends on suspected cause:

      • Stabilisation may be required.
      • Infectious cause: appropriate antibiotic therapy (see antibiotics)
      • Refer to ENT if a retropharyngeal or parapharyngeal abscess is suspected.
      • Atlantoaxial rotatory fixation: Rest, use of an Aspen collar.
      • Injury or congenital bony cause: refer Orthopaedics.
      • Dystonic reactions: Benztropine 

      Consider consultation with local paediatric team when: 

      • In cases of trauma
      • Suspicion of deep space infection of the neck
      • Cause unknown or prolonged symptoms

      Consider transfer when:

      Child is requiring care beyond the comfort level of the local provider.

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

      Consider discharge when:

      No features present on history or examination requiring further investigation.

      Appropriate follow up arranged: GP/Paediatric follow up is advisable in children discharged from ED with a diagnosis of torticollis.


      Last updated January 2019