Paediatric Torticollis

Introduction

• Large differential
• If no specific trauma or abnormal neurology, likely sternomastoid tumour
• If traumatic, treat as for C-spine fracture
  • DO NOT FORCIBLY MOVE NECK INTO ALIGNMENT

DDx

• Trauma
  • Fracture/dislocation
  • Wry neck
  • Spinal haematoma
• Infections
  • Head and neck – URTI, otitis media, mastoiditis, cervical adenitis, retropharyngeal abscess
  • Spine – Osteomyelitis, discitis, epidural abscess
  • CNS – Meningitis
• Atlantoaxial rotary fixation
  • Trauma
  • Pharyngeal infection (Grisel syndrome)
• Inflammatory
  • Juvenile idiopathic arthritis
• Neoplasm
  • CNS tumour
  • Bone tumour
• Dystonic syndromes e.g. drug reaction, idiopathic spasmodic torticollis
• Ocular dysfunction

History

• Trauma
• Infective: Fever, drooling, sore throat, dysphagia
• Metoclopramide use
• Headache, vomiting
• Strabismus
• Diplopia

Examination

• Neck
  • Midline tenderness
  • Assess ACTIVE ROM
  • Palpate for sternomastoid pseudotumour
• Hip examination
• Full neurological examination
• Eye examination
• ENT examination

Investigations

• Trauma – Imaging as for C-spine
• C-spine X-ray:
  • If traumatic, >7 days or limited ROM
• USS
  • If mass palpated and can confirm fibrous sternomastoid tumour
• CT neck and/or brain if:
  • Neurology
  • Severe pain
  • Bone anomaly suspected on exam
  • Suspicion of retropharyngeal abscess

Acute management

• Infection cause will require antibiotics (liaise with ENT)
• Atlantoaxial rotary fixation: Rest, Aspen collar, Ortho
• Injury or congenital bony anomaly: Ortho
• Dystonic reactions: Benztropine
• General measures
  • Analgesia/anti-inflammatory
  • Heat packs and massage for wry neck
  • Diazepam in some cases of spasm of SCM
• Uncomplicated acute torticollis should resolve within 7-10 days
• GP follow-up advised for all discharged patients

Congenital torticollis

• Congenital muscular torticollis is the most common cause of abnormal head posture in infants
• Characteristic features
  • Onset from birth, often noticed by friends
  • Cock-robin appearance: Head tilt with contralateral chin rotation
  • ROM limited by affected sternomastoid tightness
  • Firm painless swelling within sternomastoid muscle opposite the chin
  • Mild facial hemihypertrophy due to impaired venous return
• ALWAYS CHECK FOR HIP DYSPLASIA
• Refer to community physiotherapy for education and stretching
• Severe cases >12 months duration require referral to surgeons

Last Updated on November 20, 2021 by Andrew Crofton