Diagnosis of Torticollis
Torticollis Diagnosis: Book Excerpts
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Torticollis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
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
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
TORTICOLLIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A radiograph of the cervical spine and a thorough neurologic examination are axiomatic before one considers the problem psychogenic. An MMPI will help support the diagnosis of psychoneurosis, depression, and even malingering. Referral to a psychiatrist may be best if the patient is willing.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Torticollis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A history of painless neck deformity from birth suggests congenital torticollis; gradual onset of painful neck deformity suggests acquired torticollis. Diagnosis must rule out TB of the cervical spine, pharyngeal or tonsillar inflammations, spinal accessory nerve damage, ruptured transverse ligaments, subdural hematoma, tumors of soft tissue or bone, dislocations and fractures, scoliosis, congenital abnormalities of the cervical spine and base of the skull, rheumatoid arthritis, and osteomyelitis. In acquired torticollis, cervical spine X-rays are negative for bone or joint disease but may reveal an associated disorder (such as TB, scar tissue formation, tumor, deformities, or arthritis). Computed tomography scan or magnetic resonance imaging may help rule out pathogenic causes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Dystonia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If possible, include the patient’s family in history taking; they may be more aware of behavior changes than the patient is. Begin by asking them when dystonia occurs. Is it aggravated by emotional upset? Does it disappear during sleep? Is there a family history of dystonia? Obtain a drug history, noting especially the use of a phenothiazine or an antipsychotic. Dystonia is a common adverse effect of these drugs, and the dosage may need to be adjusted to minimize this effect.
Next, examine the patient’s coordination and voluntary muscle movement. Observe his gait as he walks across the room; then have him squeeze your fingers to assess muscle strength. (See Recognizing dystonia.) Check coordination by having him touch your fingertip and then his nose repeatedly. Follow this by testing gross motor movement of the leg: Have him place his heel on one knee, slide it down his shin to the top of his great toe, and then return it to his knee. Finally, assess fine-motor movement by asking him to touch each finger to his thumb in succession.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Stiff Neck and Torticollis:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Congenital
Congenital Muscular Torticollis (Fibromatosis Colli)
Usuallypresents at 1–2 wks of age with firm, nontender mass inlower aspect of sternocleidomastoid muscle.It is thought that fibrosis of musclein fetal life produces the mass.Diagnosis is usually clinical. Skeletal Anomalies
Short neckwith limited motion and low occipital hairline characterize Klippel-Feil syndrome.Variable number of cervical vertebrae are fused in this syndrome.Failure of normal descent of scapulais known as Sprengel deformity, which may cause limited neck movement.Malformation of first cervical vertebracalled hemiatlas also may cause torticollis.Cervical spine radiography is oftendiagnostic for these anomalies. CT or MRI also may be necessaryin some cases. Atlantoaxial Instability
Some conditions (e.g., trisomy 21, Morquiosyndrome, Klippel-Feil syndrome, and odontoid aplasia/hypoplasia)may be associated with atlantoaxial instability, which predisposesindividual to cervical subluxation. Cervical spine radiography isdiagnostic.
Infection/Inflammation
Fever, neckpain, and stiffness with or without torticollis may occur with manyinfections, including viral upper respiratory infection, pharyngitis,tonsillitis, cervical adenitis, viral myositis, meningitis, cervicalspine osteomyelitis, and spinal epidural abscess. These disordersare discussed in other chapters.Discitis may produce neck pain andstiffness but is more common in lumbar and thoracic areas (see Chap. 5, Back Pain).Juvenile rheumatoid arthritis may involvecervical spine and lead to neck pain and stiffness. Seldom occursas isolated event, and other joints are usually involved. Radiographyof cervical spine may show ankylosis of apophyseal joints, narrowingof disk spaces, and atlantoaxial dislocation (see Chap. 37, Limp). Trauma
Muscle Strain or Contusion
Upon awakeningin morning, individuals may have stiff neck and torticollis, caused bylying in particular position.Muscle strain is common with any typeof trauma, especially whiplash injury from automobile accident.Head is often fixed in 1 position,with spasm and tenderness of affected neck muscles.History and physical exam are usuallydiagnostic. Cervical spine radiography should be performed withhistory of neck trauma. Cervical Spine Fracture, Subluxation, and Dislocation
Almost alwayscaused by traumatic injuries (e.g., automobile accidents, falls,or athletic injuries).Fracture of cervical vertebra usuallyproduces pain and tenderness over involved vertebra. Cervical subluxationsor dislocations in children usually occur between C1 and C2 andbetween C2 and C3. Tenderness over involved joint, limited rangeof motion of neck, and torticollis are frequent manifestations.Cervical spine radiography usuallyconfirms diagnosis; however, CT may be necessary if uncertaintyexists about location and extent of injury. MRI is invaluable inevaluation of spinal cord and epidural space. Drugs
Drugs (e.g., haloperidol and metoclopramide)may produce acute dystonic reactions resulting in torticollis. Thesemanifestations resolve with use of diphenhydramine.
Neoplasm
Brain Tumor
Tumors ofposterior fossa may cause neck stiffness and torticollis as wellas headache, vomiting, ataxia, and visual disturbances. Head tiltmay occur to compensate for diplopia.Brainstem tumors also may produce neckstiffness as well as cranial nerve palsies and pyramidal tract signs.CT and MRI locate and define extentof these tumors. Histologic diagnosis is definitive. Cervical Spine and Spinal Cord Tumors
Tumors ofcervical spine may produce neck pain and torticollis. Most commontumor is osteoid osteoma.Spinal cord tumors also may produceneck pain and torticollis as well as arm and leg weakness, impairedsensation below the level of lesion, and bowel and bladder dysfunction.Most common spinal cord tumor is astrocytoma.Combination of cervical spine and skullradiography, CT, and MRI locate and define extent of mass. Histologicdiagnosis is definitive. Leukemia
Meningeal leukemia is another cause of neckstiffness. Diagnosis of leukemia is discussed in Chap. 38, Lymphadenopathy.Analysis of spinal fluid reveals presence of leukemic cells.
Subarachnoid Hemorrhage
Onset is acute, with intense headache andstiff neck. Most common causes in pediatric population are headtrauma and rupture of cerebral aneurysm or arteriovenous malformation(see Chap. 25, Headache).
Benign Paroxysmal Torticollis
Migrainevariant that usually occurs in infants and toddlers.Characterized by recurrent episodesof torticollis associated with vomiting, irritability, and sometimesheadache that may last hours or days.Episodes usually resolve by 2–3yrs of age. Torticollis with Gastroesophageal Reflux and Hiatal Hernia(Sandifer Syndrome)
Sandifersyndrome is association of torticollis with hiatal hernia and gastroesophagealreflux.Persistent vomiting and poor weightgain are features of this syndrome.Upper GI series can diagnose hiatalhernia. Spasmus Nutans
Constellationof nystagmus, head nodding, and torticollis.Typically occurs in children <2yrs and is generally self-limited.CT or MRI should be considered to excludea lesion (e.g., glioma) that affects anterior visual pathway. Ocular or Vestibular Disturbances
Torticollismay occur in children with visual disturbances (e.g., strabismusor refractive errors). Head may be turned to achieve binocular vision.Disturbances of vestibular system,which are discussed in Chap.73, Vertigo, also may cause torticollis.Careful ophthalmologic and neurologicexam is necessary. Psychogenic
Emotional stress may cause hysterical reactionwith inability to turn or hold head normally. History and physicalexam are diagnostic.
Diagnostic Approach
Useful distinctionis whether neck stiffness or torticollis is congenital or acquired. Congenitalmuscular torticollis can usually be diagnosed by physical exam.Cervical spine radiography can diagnose skeletal spine anomaliesand atlantoaxial instability.Most common acquired causes of neckstiffness or torticollis are muscle strain, other musculoskeletaltrauma, pharyngitis, tonsillitis, cervical adenitis, viral myositis,and meningitis.With history of trauma, cervical spineradiography should be performed.Presence of fever usually signifiesinfection.Lumbar puncture should be performedwith suspected meningitis.Fever and localized tenderness of cervicalspine suggests cervical osteomyelitis, and cervical spine radiographyand bone scintigraphy are often helpful.History and physical exam should suggestpresence of other causes of neck stiffness and torticollis.CT is initial procedure of choice forsuspected subarachnoid hemorrhage or primary brain tumor. This proceduremay be followed by MRI. >
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
TORTICOLLIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A radiograph of the cervical spine and a thorough neurologic
examination are axiomatic before one considers the problem to be
psychogenic. A Minnesota Multiphasic Personality Inventory (MMPI) will help
to support the diagnosis of psychoneurosis, depression, and even
malingering. Referral to a psychiatrist may be best if the patient is
willing.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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