See also

Cervical spine assessment  

Febrile child

Congenital torticollis

Key Points

1.  If torticollis occurs in setting of trauma, manage as Cervical spine assessment
   
2.  If the child has signs of fever, infection or abnormal neurology, appropriate imaging should be performed to establish a cause
   
3.  Most children will have a muscular torticollis and can be managed with simple analgesia 
   
   

Background 

Torticollis (twisted neck), is a non-specific sign with a large spectrum of aetiologies

Causes of acquired torticollis include:

• Muscle spasm (wry neck)
• Trauma: fracture/dislocation, spinal haematoma
• Atlantoaxial rotary subluxation/fixation
• Infection: head and neck, spine, CNS or upper lobe chest
• Inflammation: juvenile idiopathic arthritis
• Neoplasm: CNS (posterior fossa) and bone tumours
• Dystonic syndromes (idiopathic spasmodic torticollis, drug reactions)
• Ocular dysfunction
• Benign paroxysmal torticollis  
  
  

Assessment

Red flag features in Red

History

• Time course: uncomplicated acute torticollis should resolve within 7-10 days
• History of awkward position eg recent flight, different sleeping arrangement
• History of trauma
• Infective symptoms: fever (see Febrile child), increased drooling, sore throat, dysphagia
• Neurological symptoms: headache, strabismus, diplopia, photophobia, ataxia 
• Medications associated with acute dystonic reactions e.g. metoclopramide

Examination

• Midline tenderness, general neck palpation and attempt active ROM 
• Location of tenderness may assist with diagnosis, however deep pathology (eg infection) may have no external signs
• Neurologic examination
• Ophthalmologic examination
• ENT examination including dentition and lymph nodes 
• Chest examination 

Management

Investigations 

Consider:

• Cervical Spine X-ray: particularly if there is cervical spine tenderness, severe pain, persistent symptoms (≥1 week) or the child has a risk of atlantoaxial instability (eg Down syndrome, Morquio syndrome, Larsen syndrome, Marfan syndrome). See Cervical spine assessment
• CT neck and/or the brain if:
  • associated neurological symptoms are present
  • severe pain is not alleviated by analgesia or relaxants
  • bone anomaly is suspected clinically or abnormal cervical xray
  • there is suspicion of a retropharyngeal abscess

Depending on the presentation, consultation with, general medicine, orthopaedics, ENT, ophthalmology or neurology will help with decisions about imaging

Treatment

For most children, heat pack, massage and basic analgesia is appropriate treatment

Diazepam can be effective with some cases of spasm of the sternocleidomastoid

Management depends on suspected cause

• Stabilisation may be required
• Infectious cause: appropriate antibiotic therapy (see Antibiotics)
• Refer to ENT if a retropharyngeal or parapharyngeal abscess is suspected
• Atlantoaxial rotatory fixation: rest, use of a soft collar
• Injury or congenital bony cause: refer to orthopaedics
• Dystonic reactions: benztropine 

Consider consultation with local paediatric team when 

• Trauma cases
• Deep space infection of the neck suspected
• Cause unknown or prolonged symptoms

Consider transfer when

Child requires care beyond the comfort level of the local provider 

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

• No features present on history or examination requiring further investigation 
• Appropriate follow up arranged: GP/paediatric follow up is advisable in children discharged from ED with a diagnosis of torticollis

Last updated June 2020