Torticollis

Torticollis: Excerpt from In A Page: Pediatric Signs and Symptoms

Torticollis is the term used to describe an abnormal fixed head position, characterized by rotation of the neck to one side and lateral flexion of the neck to the contralateral side.

Differential Diagnosis

• Congenital muscular torticollis
  –Most likely secondary to birth trauma
  –SCM muscle is stretched during delivery, a hematoma results, and the SCM muscle spasms in response
  –SCM muscle may become fibrotic
• Brachial nerve plexus injury
  –Also associated with birth trauma
• Benign paroxymal torticollis
  –Occurs in infants and young children
  –Abrupt onset with pallor and vomiting
  –May be a migraine variant
• Muscular spasm
  –May occur after prolonged exposure to a cold stimulus such as wind
  • Dystonic reaction
    –May be drug reaction to antipsychotics, metoclopramide, prochlorperazine, trimethobenzamide
    –May be part of a dysmotility syndrome such as myasthenia gravis or Huntington chorea
  • HEENT infection
    –May occur with cervical adenitis, otitis, or mastoiditis
    –Local pressure on the neighboring SCM muscle causes irritation and spasm of the muscle
  • Atlantoaxial subluxation
    –Associated with Down syndrome, achondroplasia
    –May be secondary to fracture, infection, or malignancy of the cervical spine
  • Post-upper respiratory infection
    –May occur in young children
    –Retropharyngeal edema displaces the atlantoaxial junction
    • Ocular torticollis
      –A compensatory mechanism enacted by patients with trochlear nerve palsy or superior oblique muscle weakness
      –Head positioning results in better alignment of the affected eye with the unaffected eye, and minimizes diplopia
    • GERD, hiatal hernia
      –May manifest as neck torsion (known as Sandifer syndrome)
    • Klippel-Feil syndrome

    Workup and Diagnosis

    • History
      –Onset, duration, associated symptoms such as pain or stiffness
      –Birth history, including birth trauma, deformity at birth, other congenital malformations, syndromic features
      –Past medical history, including trauma and recent illness
      –Family history of syndromes, movement disorders migraines
    • Physical exam
      –SCM muscle examination for length, tension, masses, and range of motion
      –Cranial nerve testing, especially EOMs
    • Studies
      –AP and lateral plain films to evaluate bone structure and look for fracture
      –Open-mouth views to evaluate the odontoid
      –Flexion and extension views (passive range of motion) to evaluate cervical stability
      –CT or MRI to evaluate deep soft tissue structures of the neck
    • Labs
      –CBC with differential, ESR and blood culture if cervical osteomyelitis is suspected

    Treatment

    • Physical therapy including massage and stretching of the contracted muscle
    • For infants, selective positioning and placement of visual stimuli to promote stretching of the affected muscle
    • Surgical release of the SCM muscle
    • Surgical stabilization of the alantoaxial joint
    • Discontinuation of causative medications
    • Ophthalmic consultation for EOM impairment

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Torticollis

• Back to disease: Torticollis: Introduction
• Next Book Extract About Torticollis: TORTICOLLIS (Differential Diagnosis in Primary Care)
• More Book Extracts: All Online Books for Torticollis

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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