Acquired torticollis in children

INTRODUCTION — This topic will discuss the causes, presentation, and evaluation of acquired torticollis. Congenital muscular torticollis and evaluation of neck stiffness are discussed separately. (See "Congenital muscular torticollis: Clinical features and diagnosis" and "Approach to neck stiffness in children" and "Congenital muscular torticollis: Management and prognosis".)

DEFINITIONS AND PATHOPHYSIOLOGY — Torticollis or wryneck refers to lateral twisting of the neck that causes the head to tilt to one side with the chin turned to the opposite side (figure 1). In Latin, the word "torus" means "twisted" and "collum" means "neck".

The sternocleidomastoid (SCM) takes origin from two tendons (one from the manubrium sterni and one from the medial third of the clavicle) that combine to form a single muscle bundle running in the neck superiorly and posteriorly to insert onto the ipsilateral mastoid process of the temporal bone and the superior nuchal line of the occipital bone. Central to many but not all cases of torticollis is shortening or spasm of a SCM muscle that causes the abnormal posturing with variable degrees of neck flexion or extension [1].

Describing a child as having a "left" or "right" torticollis can result in confusion among providers, since some may be referring to the pathologic SCM muscle and others to the direction in which either the head and ear is tilted, or the chin is rotated. To avoid this, we recommend that torticollis be described in terms of the direction of both head and ear tilt AND chin rotation (eg, torticollis with head tilt to the left and chin rotation to the right (picture 1)).

Torticollis may occur in congenital and acquired forms:

●Congenital torticollis – Congenital torticollis, the most common type of torticollis, usually arises from muscular fibrosis of the SCM muscle and less commonly from neurologic or bony abnormalities. Facial asymmetry is often present in children who have congenital torticollis, but rarely in those with acquired torticollis, and is sometimes used to distinguish the two types. Congenital torticollis is more common than acquired torticollis. (See "Congenital muscular torticollis: Clinical features and diagnosis" and "Congenital muscular torticollis: Management and prognosis".)

●Acquired torticollis – In children, acquired torticollis typically results from SCM or trapezius muscle injury or inflammation. A wide variety of conditions can also cause torticollis due to cervical muscle spasm or cervical nerve irritation (table 1).

Acquired torticollis due to primary SCM spasm should result in the chin rotated to the side contralateral to the spastic SCM and the ear ipsilateral to the spastic SCM tilted to the shoulder. Other causes of acquired torticollis, such as C1-C2 (atlantoaxial) rotary subluxation can present with SCM spasm on the side to which the chin is tilted, as if trying to correct the deformity. (See 'Atlantoaxial rotary subluxation' below.)

LIFE-THREATENING CAUSES

Retropharyngeal abscess — Various respiratory and soft tissue infections of the neck may cause acquired torticollis in children (table 1). Among these, retropharyngeal abscess is one of the most common serious infections described (image 1) [2-5]. Retropharyngeal abscess occurs most commonly in children between the ages of two and four years [6]. Unwillingness to move the neck because of discomfort is a prominent presenting feature. Limitation of neck extension, with use of eye movement for upward gaze, is particularly suggestive of retropharyngeal abscess. Additional signs and symptoms of retropharyngeal abscess include fever, irritability, dysphagia, drooling, odynophagia, and respiratory distress (stridor and/or tachypnea). Retropharyngeal abscess is discussed in detail separately. (See "Retropharyngeal infections in children".)

Suppurative jugular thrombophlebitis (Lemierre syndrome) — Suppurative jugular thrombophlebitis (also known as Lemierre syndrome or postanginal sepsis) should be suspected in patients with antecedent pharyngitis, septic pulmonary emboli, and persistent fever despite antimicrobial therapy. It is caused most commonly by Fusobacterium necrophorum, which is often present in the bloodstream. Patients typically present acutely with fever (>39°C) and rigors, often accompanied by respiratory distress. Most patients have localized neck and/or throat pain. Clinical examination of the oropharynx may demonstrate ulceration, a pseudomembrane, or erythema. Tenderness, swelling, and/or induration may be observed overlying the jugular vein, over the angle of the jaw or along the sternocleidomastoid muscle. Sternocleidomastoid muscle irritation may cause torticollis. High resolution computed tomography of the neck with contrast provides the most definitive visualization of the presence and extent of the jugular thrombus. (See "Lemierre syndrome: Septic thrombophlebitis of the internal jugular vein".)

Cervical spine injury — Cervical spine fractures and subluxations are rare in children under the age of eight years. When present, they typically involve the upper cervical spine, and occur in the setting of high kinetic energy mechanisms such as motor vehicle collisions and falls. Similar to adults, older children and adolescents are vulnerable to lower cervical spine trauma caused by motor vehicle collisions and sports injuries. Signs of cervical spine injury can include neck pain, tenderness, torticollis, and stiffness. While some children with fractures of the cervical spine are unresponsive at the time of evaluation, many are awake, alert and verbal, complaining of neck pain, and have no demonstrable neurologic deficit. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

Spinal epidural hematoma — Spontaneous or traumatic epidural hematoma of the cervical spine is rare but may occur even after apparently minor trauma [7,8], after a neurosurgical procedure, or spontaneously, especially in patients with hemophilia [9,10]. It should be considered in patients with the abrupt onset of unexplained neck pain, torticollis and weakness or other neurologic findings. Emergency neurosurgical consultation and surgical decompression are indicated. (See "Disorders affecting the spinal cord", section on 'Spinal epidural hematoma'.)

Central nervous system tumor — Brain tumors located in the posterior fossa, although a rare cause of torticollis, may present with head tilt, neck stiffness, or torticollis [11-17]. Associated symptoms may include vomiting, headache, ataxia, vision disturbances, papilledema, or cranial nerve deficits. Head tilt may also result from attempts to compensate for diplopia. However, neck stiffness is believed to result from irritation of the accessory nerve by the cerebellar tonsils trapped in the occipital foramen or by tonsillar herniation. Thus, any patient with torticollis should have a thorough neurologic examination, and a posterior fossa tumor should be considered in a patient with headache, vomiting, focal neurological deficits, or torticollis that does not resolve over several days with conservative measures. (See "Clinical manifestations and diagnosis of central nervous system tumors in children".)

COMMON CAUSES

Muscle injury or inflammation — Injury or inflammation involving the sternocleidomastoid or trapezius muscles is the most common cause of acquired torticollis in children. As an example, in an observational study of 170 children with neck complaints and stiffness evaluated in a pediatric emergency department, muscle contusion, spontaneous torticollis, or viral myositis was diagnosed in approximately 60 percent of patients [18].

Clinical manifestations typically consist of minor trauma, viral illness, or no specific history followed by an abrupt onset of torticollis, often noted when the child awakens from sleep. Torticollis is frequently accompanied by neck pain and distress. Local tenderness of the sternocleidomastoid and/or trapezius muscles are present and cervical spine range of motion is limited. Examination of the pharynx, cervical lymph nodes, and nervous system and plain radiographs of the cervical spine are normal. Muscular torticollis typically resolves within one week with supportive treatment [18]. (See 'Treatment' below.)

Acute infections — Acute infections with compensatory muscle spasm or referred pain are the second leading cause of acquired torticollis in children accounting for 20 percent of neck complaints in one series [18]. The most common infections associated with torticollis comprise viral or streptococcal pharyngitis, cervical adenitis, retropharyngeal abscess, parapharyngeal abscess, and viral upper respiratory tract infections. Retropharyngeal abscess is considered life-threatening. (See 'Retropharyngeal abscess' above.)

Less common infectious etiologies include, osteomyelitis, pyomyositis [19], diskitis, tuberculosis (Pott disease), and right upper lobe pneumonia (table 1).

Children with infectious conditions causing torticollis frequently have fever with other signs of infection (eg, exudative pharyngitis, cervical spine tenderness, or tender and enlarged lymph nodes).

Atlantoaxial rotary subluxation — Atlantoaxial rotary subluxation (AARS), a rotational displacement of C1 on C2, is thought to be caused by retropharyngeal edema that leads to laxity of the ligaments and capsular structures at the atlantoaxial level and permits rotary deformity [20]. Nontraumatic atlantoaxial subluxation is sometimes called Grisel syndrome (image 2).

Children between 6 and 12 years of age are affected most frequently [2]. The pathoanatomy of AARS is poorly understood. There may even be different pathoanatomies associated with different etiologies. In some cases, there appears to be no motion between C1 and C2, similar perhaps to other synovial joints such as the knee "locked" in one position. In other cases, motion is present but limited. AARS may occur after minor trauma, pharyngeal surgery (eg, tonsillectomy or adenoidectomy), an inflammatory process of the neck (causing spasm of the SCM), or upper respiratory tract infection [21-29].

Clinical manifestations and diagnosis — Most children present with pain, torticollis, and decreased range of motion following minor trauma [30] or infection of the head and neck. In contrast to congenital muscular torticollis, the head tilts away from the affected SCM muscle so that the SCM muscle on the "chin" side is tight and tender (picture 1) [20,31]. Children with atlantoaxial rotary subluxation also may have tenderness of the spinous process of the axis, displacement of the spine of the axis to the same side as the torticollis, reduction in the size of the nasopharynx, and a change in nasal resonance [32]. In addition, because a portion of the second cervical nerve (which innervates the occipital dermatome) runs in the capsule of the atlantoaxial joint, they may complain of unilateral occipital pain [20].

The differential diagnosis of atlantoaxial subluxation includes abnormalities of the upper spine (eg, fractures, tumors, and osteomyelitis), and tumors of the posterior fossa or spinal cord [31].

Cervical spine immobilization and cervical radiographs are warranted, particularly when there is a clear traumatic mechanism of injury. In addition, cervical spine radiographs should be obtained in patients who have conditions that are associated with atlantoaxial instability (eg, Down syndrome, Morquio syndrome, Larsen syndrome, Marfan syndrome, and cervical spine arthritis) [33-39]. Torticollis or neck pain in patients with these conditions, particularly when associated with neurologic symptoms (eg, gait abnormalities, clumsiness, change in bowel or bladder habits, hyperreflexia) may indicate spinal cord injury [33,34,40]. The cervical spine should be immobilized before imaging [41]. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Pediatric cervical spinal motion restriction".)

Radiographic evaluation demonstrates asymmetry of the odontoid in relation to the atlas (image 3) [20]. Open-mouth views of the odontoid demonstrate the best view, but may be difficult to obtain because the limited range of motion prevents proper positioning [31]. Dynamic CT, with the head turned (actively, never passively) as far as possible to the right and to the left, may be necessary to verify the subluxation (picture 1) [42,43].

Management — Treatment for atlantoaxial subluxation depends upon the severity and duration of the abnormality [30]. For acute (less than one week in duration) and minor cases, soft cervical collar, rest, and analgesics may be adequate. For severe cases, cervical traction followed by immobilization and surgical intervention may be indicated [43-46]. Orthopedic consultation should be obtained when the pain is severe. Neurosurgical consultation should be obtained when there is evidence of neurologic deficit.

OTHER CAUSES

Ocular torticollis — Children who have disorders of ocular motility or alignment (eg, strabismus) may tilt their heads to avoid diplopia. These disorders are discussed in detail separately. (See "Fourth cranial nerve (trochlear nerve) palsy" and "Sixth cranial nerve (abducens nerve) palsy", section on 'Clinical manifestations' and "Evaluation and management of strabismus in children", section on 'Causes'.)

Spasmus nutans — Spasmus nutans includes a triad of acquired nystagmus, head nodding, and torticollis. The presence of all three features is not necessary for diagnosis; head nodding and nystagmus are most common, with head turn in only 30 percent. The age at onset is usually 6 to 12 months, but can be up to several years [47]. This disorder is discussed in detail separately. (See "Pendular nystagmus", section on 'Spasmus nutans'.)

Benign paroxysmal torticollis — Benign paroxysmal torticollis is a self-limited condition characterized by recurrent episodes of head tilt often accompanied by vomiting, pallor, irritability, ataxia, or drowsiness that usually presents in the first few months of life. The periodic episodes of torticollis can randomly alternate from side to side. The individual attacks typically last for hours but occasionally last for days. The episodes occur less frequently as the child gets older and disappear by five years of age in most cases [48-50].

The pathogenesis of benign paroxysmal torticollis has not been determined, although specific genetic variants associated with atypical features, including psychomotor delay and cognitive dysfunction, have been described [51]. It is considered to be a "migraine equivalent" disorder [52]. Some patients go on to develop migraine headaches or benign paroxysmal vertigo of childhood [53]. Electromyographics studies in one infant demonstrated continuous electrical discharges over the sternocleidomastoid muscle during the episodes, indicating that the torticollis was a dynamic phenomenon [54].

Benign paroxysmal torticollis is occasionally confused with congenital muscular torticollis. However, in contrast to congenital muscular torticollis, the torticollis is usually accompanied by vomiting, pallor, irritability, ataxia, or drowsiness. The associated findings can mimic seizures or posterior fossa tumors. Electroencephalogram (EEG) or neuroimaging may be necessary to exclude these disorders. The EEG is usually normal in patients with benign paroxysmal torticollis [55-59]. (See "Nonepileptic paroxysmal disorders in infancy".)

The diagnosis of benign paroxysmal torticollis is made with careful attention to the history of the episodes and to the details of the clinical presentation. Often, it is useful to have photographic or video recordings of the attacks (made by the parents or caregivers). Neurologic consultation may also be useful in the initial stages of evaluation. (See "Seizures and epilepsy in children: Clinical and laboratory diagnosis" and "Overview of the clinical features and diagnosis of brain tumors in adults".)

Dystonic reaction — Torticollis can occur as part of a dystonic reaction to certain medications, including phenothiazines, carbamazepine, and phenytoin. A dystonic reaction is an acute spasm of muscle groups characterized by fixed upper gaze, neck twisting, grimace, clenched jaw, and difficulty in speech. It is often painful and can be frightening to the patient. Dystonic reactions that are drug-induced can be treated with diphenhydramine or diazepam. (See "First-generation (typical) antipsychotic medication poisoning", section on 'Acute extrapyramidal syndromes' and "Hyperkinetic movement disorders in children", section on 'Acute dystonic reaction'.)

Sandifer syndrome — Sandifer syndrome is the term used to describe gastroesophageal reflux with torsion spasms of the neck and abnormal posturing. The torticollis in these patients, similar to those with benign paroxysmal torticollis, occurs intermittently and alternates direction [60]. Additional symptoms and complications of gastroesophageal reflux may or may not be present. These include regurgitation, anorexia, hematemesis, irritability, anemia, failure to thrive, asthma, chronic cough, or hoarseness (see "Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents"). Antireflux therapy is usually effective in treating the dystonic posturing and torticollis [60-62]. (See "Management of gastroesophageal reflux disease in children and adolescents".)

Miscellaneous — Other rare but important conditions that may be associated with acquired torticollis are listed in the table (table 1) and include [2]:

●Cervical bone or disk abnormality:

•Intervertebral disk calcification [63]

•Benign tumors of the cervical spine (osteoid osteoma) [11,45]

•Bony abnormalities of the cervical spine (eg, occipitocervical synostosis) [11,45]

•Spondylitis [64]

•Juvenile idiopathic arthritis (JIA) including odontoid erosion with pannus of the cervical spine [65] (see "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis", section on 'Clinical manifestations')

●Atriovenous malformation [66]

●Neurologic conditions:

•Idiopathic intracranial hypertension (see "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis")

•Arnold Chiari malformation (see "Chiari malformations", section on 'Clinical manifestations')

These entities are sometimes mistaken for self-limited muscular torticollis. They can often be differentiated by the presence of other clinical manifestations:

●Brainstem and posterior fossa tumors – Vomiting, ataxia, and cranial nerve deficits (see "Clinical manifestations and diagnosis of central nervous system tumors in children", section on 'Clinical manifestations')

●AV malformation – Seizures, hemiplegia

●Spondylitis – Local disk tenderness

●JIA – Arthritis and other systemic manifestations (see "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis", section on 'Clinical manifestations')

Furthermore, these patients will not respond to supportive care. Definitive diagnosis frequently requires additional laboratory studies and computed tomography or magnetic resonance imaging of the brain and neck.

CLINICAL PRESENTATION AND APPROACH — In contrast to congenital torticollis, the child with acquired torticollis is usually older, and the onset of torticollis more acute.

The first step in the evaluation of a child with torticollis is to determine whether the child requires immediate intervention due to the presence of life-threatening trauma. Thus, if serious cervical spine injury is suspected immediate cervical spine immobilization and thorough neurologic examination is indicated. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Pediatric cervical spinal motion restriction".)

Urgent evaluation also is necessary in children with torticollis and the following findings:

●Fever, drooling, and stridor suggestive of retropharyngeal abscess (see 'Retropharyngeal abscess' above)

●Headache, vomiting, neurologic deficit, and/or ataxia consistent with a posterior fossa brain tumor or spinal epidural hematoma (see 'Central nervous system tumor' above and 'Spinal epidural hematoma' above)

●Fever, pharyngitis, tachypnea, and neck tenderness over the internal jugular vein suggesting a suppurative jugular thrombophlebitis (see 'Suppurative jugular thrombophlebitis (Lemierre syndrome)' above)

History — The history helps to narrow the broad differential diagnosis (table 1). Important questions to consider include:

●How old is the child? – Retropharyngeal abscess, ocular torticollis, benign paroxysmal torticollis, spasmus nutans, and Sandifer syndrome from gastroesophageal reflux disease are most commonly seen in infants and young children. Muscular torticollis, streptococcal pharyngitis, and atlantoaxial rotary subluxation are more common in school age children.

●When did the torticollis develop? – Muscular torticollis commonly presents upon awakening from sleep. Dystonic reactions typically occur within 24 hours of taking medications with extrapyramidal effects (eg, metoclopramide or promethazine). Torticollis with arching after eating suggests Sandifer syndrome.

●How long has the torticollis been present? – Acquired torticollis lasting more than one week is not consistent with muscular torticollis and suggests an underlying structural or infectious etiology.

●Was the onset acute or insidious? – Torticollis caused by muscle injury or inflammation, cervical spine injury, dystonic reaction, Sandifer syndrome, or spinal epidural hematoma typically has an abrupt onset. Presentations other than an abrupt onset are concerning for an underlying infectious process, central nervous system (CNS) tumor, cervical spine or CNS malformation, or ocular torticollis.

●Is there a history of trauma? – Cervical spine injury must be sought in these patients. Muscular torticollis and atlantoaxial rotary subluxation may also occur after minor trauma.

●Is there a history of fever? – Fever suggests suppurative neck infections (eg, retropharyngeal or parapharyngeal abscess), suppurative jugular thrombophlebitis, or other acute infections (eg, cervical adenitis, pharyngitis, right upper lobe pneumonia, cervical diskitis, or cervical osteomyelitis).

●Is there a recent history of infection or surgery in the head or neck? – Atlantoaxial subluxation may occur after an upper respiratory tract infection, pharyngeal surgery, or pharyngitis. Grisel syndrome is sometimes used to describe these nontraumatic forms of atlantoaxial rotary subluxation.

●Are there associated symptoms, such as vomiting, headache, neurologic deficit, or ataxia? – These findings are concerning for a CNS tumor or spinal epidural hematoma as the underlying cause for torticollis.

●Is there a history of exposure to medications or drugs? Dystonic reactions may occur at varying times and repetitively after taking medicines with extrapyramidal side effects (eg, metoclopramide or promethazine).

Physical examination — The physical examination should be directed towards verifying the diagnosis of torticollis and identifying possible treatable causes (eg, pharyngitis, lymphadenitis, or dystonic reaction) [67,68]. Examination of the head, neck, eyes, upper respiratory tract, and nervous system are particularly important [32].

●The presence of craniofacial asymmetry often indicates congenital or long-standing torticollis. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Clinical features'.)

●A short neck with a low posterior hair line may indicate a bony cervical spine anomaly (eg, occipitocervical synostosis).

●The active range of motion of the neck should be assessed; the normal child should be able to flex the chin to the chest, touch the ear to the ipsilateral shoulder, and turn the head 90 degrees to the right or left to touch the chin to the contralateral shoulder. Passive range of motion testing should be performed with caution because of the risk of vertebral subluxation.

●The presence of ocular torticollis should be evaluated as follows:

•The corneal light reflex test (figure 2) and the cover/uncover test (figure 3) should be performed to determine whether the child has strabismus or superior oblique palsy. (See "Evaluation and management of strabismus in children", section on 'Evaluation'.)

•Nystagmus and/or head nodding suggests Spasmus nutans. (See 'Spasmus nutans' above.)

●The fundi should be examined for papilledema, suggestive of an intracranial mass or idiopathic intracranial hypertension [69]. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".)

●The pharynx should be examined for signs of exudate and inflammation.

●Drooling or stridor suggest retropharyngeal abscess. (See "Retropharyngeal infections in children".)

●Enlarged lymph nodes in the neck suggest a recent or ongoing head or neck infection.

●Tenderness of the SCM muscle may suggest trauma (muscle injury) or myositis resulting in the chin tilting to the same side. However, the muscle may also be tender from spasm in cases where the chin is tilted to the opposite side.

●Point tenderness over the cervical spine may indicate underlying fracture, subluxation, diskitis, or osteomyelitis. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

●Tachypnea and rales on lung auscultation indicate a pneumonia

●The neurologic examination should include testing for weakness and sensory deficits, ataxia, and gait abnormalities which, if present, suggest brainstem and posterior fossa tumors.

Imaging — The modality of imaging for acquired torticollis depends upon the age of the patient and the most likely etiology as follows [70] (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' and "Approach to neck stiffness in children", section on 'Radiographic imaging'):

●Plain radiography – Cervical spine radiographs should be obtained in all patients who have a history of trauma, persistent torticollis, findings suggestive of vertebral involvement, or severe pain [67]. Plain radiography is usually diagnostic in patients with serious cervical spine fracture or anomalies. Plain films do not always detect rotary atlantoaxial subluxation or atlantoaxial subluxation and are frequently normal in patients with vertebral cervical osteomyelitis or diskitis. It is typically impractical to obtain odontoid views in children under five years. (See 'Atlantoaxial rotary subluxation' above.)

In a patient with a retropharyngeal abscess, but not lateral or parapharyngeal abscesses, lateral radiographs of the neck may reveal soft tissue swelling anterior to the upper cervical vertebral bodies. CT with intravenous contrast is helpful in equivocal cases, especially those with an apparently widened retropharyngeal space seen on plain neck radiographs that may be due to inadequate neck extension or inadequate inspiration and is also indicated to identify parapharyngeal and deep neck abscesses. (See "Retropharyngeal infections in children", section on 'Imaging'.)

●Computed tomography – If a fracture or subluxation is found or suspected, computed tomography (CT) of the cervical spine can better define an injury. CT shows exquisite bone detail of the cervical spine and demonstrates fractures and extent of bone injury better than magnetic resonance imaging (MRI); multidetector CT allows rapid acquisition of thin-section images resulting in improved spatial resolution and decreased need for sedation in children [71].

●Magnetic resonance imaging – MRI is the study of choice to demonstrate posterior fossa tumors, spinal epidural hematomas, cervical vertebral osteomyelitis or infectious diskitis although CT can be helpful with some of these conditions.

Indications for additional imaging and the approach for children with serious cervical spine trauma, deep neck infection, or other nontraumatic causes of neck stiffness besides muscular torticollis are discussed in detail separately. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' and "Approach to neck stiffness in children", section on 'Radiographic imaging'.)

TREATMENT — The treatment of acquired torticollis depends upon the underlying cause:

●Most children will have muscular torticollis. These patients typically will have resolution of symptoms within a few days with the following management:

•Nonsteroidal antiinflammatory drugs (NSAIDs) and a cervical collar (soft or rigid) to relieve the pain and discomfort.

•A short course of diazepam or muscle relaxants may be tried in children who do not respond to NSAIDs.

•Follow-up must be assured and patients with persistent torticollis not responsive to supportive care warrant additional evaluation for other etiologies.

●Emergency conditions such as retropharyngeal abscess, suppurative jugular thrombophlebitis, cervical spine fracture or subluxation, spinal epidural hematoma, or central nervous system tumor warrant prompt subspecialty consultation and treatment. (See "Retropharyngeal infections in children", section on 'Management' and "Clinical manifestations and diagnosis of central nervous system tumors in children".)

●Appropriate antibiotic therapy is indicated in children who have pharyngitis, lymphadenitis, or other infectious processes as the underlying cause. (See "Cervical lymphadenitis in children: Diagnostic approach and initial management", section on 'Initial laboratory evaluation and management'.)

●Treatment for atlantoaxial subluxation depends upon the severity and duration of the abnormality. (See 'Atlantoaxial rotary subluxation' above.)

●Torticollis related to strabismus may respond to treatment of the underlying disorder. (See "Fourth cranial nerve (trochlear nerve) palsy", section on 'Treatment and prognosis' and "Evaluation and management of strabismus in children", section on 'Overview of management'.)

●Dystonic reactions that are drug-induced should be treated initially with diphenhydramine. (See "Hyperkinetic movement disorders in children", section on 'Acute dystonic reaction'.)

●Antireflux therapy is indicated in children who have gastroesophageal reflux [60-62]. (See "Management of gastroesophageal reflux disease in children and adolescents".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Torticollis in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Torticollis or wryneck refers to lateral twisting of the neck that causes the head to tilt to one side with the chin turned to the opposite side. In children, acquired torticollis commonly results from sternocleidomastoid (SCM) or trapezius muscle injury or inflammation. (See 'Definitions and pathophysiology' above.)

●Causes – Injury or inflammation from a variety of conditions can cause spasm of cervical muscles or irritation of cervical nerves, resulting in torticollis. Underlying conditions range in severity from benign to potentially life-threatening (table 1). (See 'Life-threatening causes' above and 'Common causes' above and 'Other causes' above.)

●Clinical presentation and diagnostic approach – With acquired torticollis, the head is tilted toward the shortened SCM, and the chin rotated toward the opposite side. In contrast to congenital torticollis, the child is usually older, and the onset of torticollis more acute. (See 'Clinical presentation and approach' above.)

History, physical examination, and cervical spine imaging will determine the etiology for acute acquired torticollis in most patients. (See 'History' above and 'Physical examination' above and 'Imaging' above.)

●Treatment – The treatment of acquired torticollis depends upon the underlying cause. (See 'Treatment' above.):

•Acute traumatic torticollis – Patients with acute traumatic torticollis warrant immediate cervical spine immobilization and thorough neurologic examination to assess for a spinal cord injury. (See 'Treatment' above.)

•Other emergency conditions – Emergency conditions such as retropharyngeal abscess, suppurative jugular thrombophlebitis, cervical spine fracture or subluxation, spinal epidural hematoma, or central nervous system tumor warrant prompt subspecialty consultation and treatment. (See 'Treatment' above.)

•Minor muscle injury – Most children will have minor muscle injury or inflammation as the cause of their torticollis. These patients will have resolution of symptoms in a few days and are treated with nonsteroidal antiinflammatory drugs (NSAIDs) and a cervical collar (soft or rigid) for comfort. (See 'Treatment' above.)