Clinical Practice Guidelines

Torticollis


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

  • See also

    Background to condition

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

    Congenital torticollis:

    • Congenital muscular torticollis is the most common cause of abnormal head posture in infants (usually noted in first months of life)
    • There are a number of rarer congenital causes including those involving skin, bone, CNS and eyes.

    Acquired torticollis:

    • 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 

    Assessment

    If torticollis occurs in setting of trauma, manage as   Cervical Spine Injury

    History:

    • 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 

    Examination:

    • 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 

    Investigation: 

    If torticollis occurs in setting of trauma, see   Cervical spine injury.

    Consider:

    • Cervical Spine xray: particularly if there is cervical spine tenderness, severe pain, persistent symptoms (≥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.
      • 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. 

    Acute management

     If torticollis occurs in setting of trauma, manage as Cervical spine injury.

    Management depends on suspected cause:

    • Stabilisation may be required.
    • Infectious cause: appropriate antibiotic therapy e.g. iv Timentin.
      • 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.
    • Congenital muscular torticollis - refer to community physiotherapy for education and stretching exercises. Severe cases persistent greater than 12 months warrant a surgical opinion. Congenital Muscular Torticollis Info Sheet
    • Dystonic reactions: Benztropine 

    General measures:

    • 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.  

    Consider consultation with local paediatric team: 

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

    When to consider transfer to tertiary centre:

    • Child requiring care beyond the comfort level of the hospital.

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

    Additional notes and follow up:

    • Uncomplicated acute torticollis should resolve within 7 - 10 days without complication.
    • GP/Paediatric follow up is advisable in children discharged from ED with a diagnosis of torticollis.

    Last updated September 2012