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