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Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

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TORTICOLLIS

DESCRIPTION

  • Lateral twisting or rotation of neck; also called wryneck
  • This chapter will focus on acquired torticollis, not congenital

PATHOPHYSIOLOGY

  • Injury or inflammation of sternocleidomastoid (SCM) or trapezius muscle
  • Most common in school age children
  • Acute infection with referred pain to SCM or compensatory muscle spasm

ETIOLOGY

  • Minor trauma/inflammation most common
  • Viral myositis
  • Viral or Streptococcal pharyngitis
  • Upper respiratory infection
  • Upper lobe pneumonia
  • Dystonic drug reaction
  • Sandifer syndrome

ALERT – LIFE THREATENING CAUSES

  • Retropharyngeal abscess (RPA)
  • Lemierre syndrome (suppurative jugular thrombophlebitis)
  • Spinal epidural hematoma
  • Posterior fossa tumor
  • Cervical spine injury

DIFFERENTIAL DIAGNOSIS

  • Atlanto-axial rotary subluxation (AARS) – rotational displacement of C1 on C2, due to retropharyngeal edema, laxity of ligaments that allows rotary deformity
    • 6-12 years
    • Seen after minor trauma, pharyngeal surgery, upper respiratory infection
    • Grisel syndrome – non-traumatic AARS
  • Cervical spine inflammation or tumor
  • Spondylitis
  • Juvenile idiopathic arthritis
  • Osteoid osteoma
  • Benign paroxysmal torticollis
  • Ocular torticollis

ALERT

  • If trauma or subluxation suspected, immobilize cervical spine immediately

DIAGNOSIS

History

  • Sudden onset of neck pain and distress upon awakening from sleep
  • Minor falls/trauma
  • Medication history eg. phenothiazines, carbamazepine, phenytoin cause dystonic reactions

PHYSICAL EXAM

  • SCM spasm and tenderness with ipsilateral head tilt and contralateral chin tilt
  • Limited cervical spine motion
  • Normal pharynx, lymph nodes, nervous system

ALERT

  • Avoid passive range of motion because of risk of vertebral subluxation
  • Facial asymmetry if congenital or long-standing
  • AARS: SCM spasm on ipsilateral side of chin tilt, tenderness of C2 spinous process, change in nasal resonance, unilateral occipital pain
  • Fever, drooling, stridor suggests RPA
  • Headache, vomiting, ataxia or neurologic deficits suggests posterior fossa tumor or spinal epidural hematome
  • Fever, pharyngitis, tachypnea, tenderness over internal jugular vein suggests Lemierre’s
  • Point cervical spine tenderness in fractures, subluxation, diskitis, osteomyelitis
  • Tachypnea and rales in pneumonia

DIAGNOSTIC TESTS & INTERPRETATION

Lab

  • Initial Lab Tests
  • Usually not indicated
  • Rapid streptococcal or Monospot testing

Imaging

  • Usually not indicated
  • Cervical spine xray in trauma, persistent cases, severe pain, point tenderness
  • Open mouth odontoid X-ray may visualize asymmetry of odontoid in relation to atlas in AARS
  • Chest xray if indicated
  • CT cervical spine if RPA, fracture or subluxation suspected
  • CT with contrast if Lemierre’s suspected to visualize jugular venous thrombosis
  • MRI for tumors, cervical osteomyelitis, diskitis suspected

TREATMENT

MEDICATION

First Line

  • NSAIDS
  • Cervical collar (soft or rigid) for comfort
  • Muscle relaxants like benzodiazepine eg. Diazepam

Second Line

  • Treat any underlying secondary cause e.g. antibiotics for streptoccal pharyngitis, diphenhydramine or diazepam for dystonic reactions

SURGERY / OTHER PROCEDURES

  • Prompt surgical or subspecialty consultation evaluation if life-threatening cause found

FOLLOW UP

  • Discharge instructions and medications
  • NSAIDS
  • Short course of benzodiazepine
  • Cervical collar (soft or rigid) for comfort

Activity

  • Limit activity until resolved

Patient Monitoring

  • Follow up in 1 week
  • If not resolved, needs further evaluation for other causes

PROGNOSIS

  • Usually resolves in 1 week

REFERENCES

  • Torticollis. In: Essentials of Musculoskeletal Care, 2nd, Greene WB (Ed), American Academy of Orthopedic Surgeons, Rosemont 2001. p.719
  • Torticollis. In: Signs and Symptoms in Pediatrics, 3rd, Tunnessen WW, Roberts KB (Eds), Lippincot Williams & Wilkins, Philadelphia 1999. p.353

PEARLS AND PITFALLS

  • Chin should point away from affected SCM muscle
  • Any neurologic deficit should prompt evaluation for other causes

Thank You To Our SPUC Group Bill Members

GROUP BILLING
10% or 15% discount on membership dues. Receive a 10% discount on member dues in the group billing program for groups of 34 members or fewer for your practice or institution. Groups of 35 or more members will receive a 15% discount. The Society will send one comprehensive renewal notice to include all the SPUC members in your practice or institution. Contact Greg Leasure, Membership Director, at [email protected] or 804-565-6393.

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2209 Dickens Road, Richmond, VA 23230-2005 · Phone: 804-565-6393 · Fax: 804-282-0090 · [email protected]

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