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Acquired torticollis in children

Authors: Charles G Macias, MD, MPH, Vanthaya Gan, MD

Section Editors: Richard G Bachur, MD, William Phillips, MD, Glenn C Isaacson, MD, FAAP
Deputy Editor: James F Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Nov 2016. | This topic last updated: Oct 07, 2015.

INTRODUCTION — Torticollis is the term for the clinical finding of a twisted or rotated neck. In
Latin, the word "torus" means "twisted" and "collum" means "neck". Torticollis, also called wryneck,
is a common complaint in children and may be congenital or acquired. 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 [1]. Congenital torticollis is more common than
acquired torticollis.

The causes, presentation, and evaluation of acquired torticollis will be reviewed below. 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 — 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). 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 [2].

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. (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) [3-6]. Retropharyngeal abscess occurs most
commonly in children between the ages of two and four years [7]. 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 "Suppurative
(septic) thrombophlebitis", section on '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 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 [8,9], or spontaneously, especially in
patients with hemophilia [10,11]. 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.

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 [12-17]. 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]. Viral or streptococcal pharyngitis, retropharyngeal abscess,
parapharyngeal abscess, and viral upper respiratory tract infections comprise the most common
infections associated with torticollis. Retropharyngeal abscess is considered life-threatening. (See
'Retropharyngeal abscess' above.)

Less common infectious etiologies include cervical adenitis, osteomyelitis, 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 [19].
Children between 6 and 12 years of age are affected most frequently [3]. 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 [20-28]. These instances of nontraumatic atlantoaxial subluxation are
sometimes called Grisel syndrome (image 2).
 Clinical manifestations and diagnosis — Most children present with pain and decreased
range of motion following minor trauma 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) [19,29]. 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 [30]. 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 [19].

The differential diagnosis of atlantoaxial subluxation includes fractures, tumors, and osteomyelitis
of the upper cervical spine, and tumors of the posterior fossa or spinal cord [29].

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) [31-37].
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 [31,32,38]. The cervical spine should be immobilized
before imaging [39]. (See "Evaluation of cervical spine injuries in children and adolescents" and
"Pediatric cervical spine immobilization".)

Radiographic evaluation demonstrates asymmetry of the odontoid in relation to the atlas [19].
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 [29]. 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 [40,41].

Management — Treatment for atlantoaxial subluxation depends upon the severity and duration
of the abnormality. 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 [41-44]. 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 in children" and "Evaluation and management of
strabismus in children", section on 'Strabismus' and "Sixth cranial nerve (abducens nerve) palsy in
children", section on 'Clinical manifestations'.)

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 [45]. 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 in most cases by five years of age [46,47].

The pathogenesis of benign paroxysmal torticollis has not been determined. It is considered to be
a "migraine equivalent" disorder [48]. Some patients go on to develop migraine headaches or
benign paroxysmal vertigo of childhood [49]. Electromyographics studies in one infant
demonstrated continuous electrical discharges over the sternocleidomastoid muscle during the
episodes, indicating that the torticollis was a dynamic phenomenon [50].

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
[51-55]. (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). Neurologic consultation may also be useful
in the initial stages of evaluation. (See "Clinical and laboratory diagnosis of seizures in infants and
children" and "Clinical presentation and diagnosis of brain tumors".)

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 [56].
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 [56-58]. (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 [3]:

● Cervical bone or disk abnormality:

• Intervertebral disk calcification [59]

• Benign tumors of the cervical spine (osteoid osteoma) [12,43]

 • Bony abnormalities of the cervical spine (eg, occipitocervical synostosis) [12,43]

• Spondylitis [60]

• Juvenile idiopathic arthritis (JIA) (see "Systemic juvenile idiopathic arthritis: Clinical
manifestations and diagnosis", section on 'Clinical manifestations')

● Atriovenous malformation [61]

● 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 (eg, vomiting, ataxia, or other
neurologic findings in patients with brainstem and posterior fossa tumors; hemiplegia in patients
with AV malformation; local disk tenderness in children with spondylitis; arthritis in children with
JIA). 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 of cervical spine injuries in children and adolescents"
and "Pediatric cervical spine immobilization".)

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, 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).

Examination — The physical examination should be directed towards verifying the diagnosis of
torticollis and identifying possible treatable causes (eg, pharyngitis, lymphadenitis, or dystonic
reaction) [1,62]. Examination of the head, neck, eyes, upper respiratory tract, and nervous system
are particularly important [30].

● 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
"Fourth cranial nerve (trochlear nerve) palsy in children", section on 'Clinical evaluation'
and "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 [63]. (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 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 [64] (see "Evaluation of cervical spine injuries in children
and adolescents", section on 'Radiologic evaluation' 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 [1]. 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
[65].

● 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 of cervical spine injuries in children and
adolescents", section on 'Radiologic evaluation' 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.

● Emergent 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 "Treatment and prevention of
streptococcal tonsillopharyngitis", section on 'Treatment' and "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 in children", section on 'Treatment' 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 [56-58]. (See
"Management of gastroesophageal reflux disease in children and adolescents".)

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

SUMMARY AND RECOMMENDATIONS

● 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. A wide variety of
conditions can cause cervical muscle spasm or cervical nerve irritation (table 1). (See
'Definitions' above.)

● 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.)

● 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 'Examination' above and
'Imaging' above.)

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

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

● Emergent 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.)
● 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.)

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Topic 6462 Version 17.0

GRAPHICS

Torticollis in a child

Children with torticollis have lateral neck twisting that causes the head to tilt to
one side with the chin turned out to the opposite side. Sternocleidomastoid and
trapezius muscle injury and inflammation are common causes of acquired
torticollis.

Graphic 89148 Version 1.0

Acquired torticollis with atlantoaxial rotary subluxation

(A) The head of this child is in the typical position of rotatory atlanto-axial subluxation: tilted to
the left, with the chin rotated to the right. Unlike in patients who have congenital muscular
torticollis, the right sternocleidomastoid muscle is tight, suggesting an attempt to straighten
the neck.
(B, C) Dynamic computed-tomography scans of the upper cervical spine in a patient who had
rotatory atlanto-axial subluxation. (B) The head is rotated approximately 45 degrees to one
side, with the contralateral lateral mass of the first cervical vertebra moving forward on the
cephalad articulating facet of the second cervical vertebra. (C) The head cannot be rotated past
the midline, and the relationship of the first and second cervical vertebrae is unchanged.

Reproduced with permission: Phillips WA, Hensinger RN. The management of rotatory atlanto-axial
subluxation in children. J Bone Joint Surg 1989; 71-A: 664. Copyright © 1989 Journal of Bone and
Joint Surgery, Inc. All rights reserved. http://jbjs.org/.

Graphic 89489 Version 3.0

Differential diagnosis of acquired torticollis in children

Trauma Neurogenic
C1-C2 subluxation Myasthenia gravis

C1-C2 dislocation Poliomyelitis

Clavicle fracture Dystonia

Cervical spine fracture Kernicterus

Muscle injury Huntington chorea

Ligamentous injury Wilson disease

Spinal epidural hematoma Neuritis of spinal accessory nerve

Infection Ocular
Upper respiratory infection Superior oblique palsy

Cervical adenitis Congenital nystagmus

Pharyngitis Refractive errors

Retropharyngeal abscess Strabismus

Upper lobe pneumonia Miscellaneous

Cervical osteomyelitis
Myositis or fibromyositis
Cervical diskitis
Gastroesophageal reflux
Tuberculosis
Juvenile idiopathic arthritis
Lemierre syndrome
Spasmus nutans

Tumors Benign paryoxysmal torticollis

Posterior fossa Drug-induced

Intraspinal Ligamentous laxity

Osteoid osteoma Functional torticollis

Eosinophilic granuloma Polymyositis

Calcification of the intervertebral disks

Idiopathic intracranial hypertension

(pseudotumor cerebri)

Adapted from: Torticollis. In: Signs and symptoms in pediatrics, 3rd ed, Tunnessen WW, Roberts KB (Eds),
Lippincott, Williams and Wilkins, Philadelphia, 1999. p.353.

Graphic 76604 Version 6.0

Retro- and parapharyngeal abscess

The computed tomography of the neck shows retro- and parapharyngeal

abscess (A, B) as indicated by a low-density core, soft-tissue swelling,
obliterated fat planes, mass effect, and rim enhancement.

Graphic 51505 Version 3.0

Grisel syndrome with atlantoaxial subluxation and
torticollis

This patient developed torticollis with atlantoaxial cervical spine subluxation

caused by inflammation after adenoidectomy detected on computed tomography
of the neck.

Courtesy of Glenn Isaacson, MD.

Graphic 59495 Version 4.0

Corneal light reflex

The corneal light reflex test involves shining a light onto the child's eyes from a
distance and observing the reflection of the light on the cornea with respect to
the pupil. The location of the reflection from both eyes should appear symmetric
and generally slightly nasal to the center of the pupil.
(A) Normal corneal reflex.
(B) Corneal light reflex in esotropia.
(C) Corneal light reflex in exotropia.

Graphic 63631 Version 3.0

 Cover/uncover test

Illustration demonstrating technique for cover/uncover test to test for strabismus.

Child's eyes appear to be in good alignment. Left eye is then covered for 5 seconds.
When card is removed, left eye moves back to alignment. This "drifting" indicates
phoria.

Reproduced with permission from: LifeART. Copyright ©2009 Lippincott Williams & Wilkins.
All rights reserved.

Graphic 68374 Version 1.0

Contributor Disclosures
Charles G Macias, MD, MPH Nothing to disclose Vanthaya Gan, MD Nothing to
disclose Richard G Bachur, MD Nothing to disclose William Phillips, MD Nothing to
disclose Glenn C Isaacson, MD, FAAP Nothing to disclose James F Wiley, II, MD, MPH Nothing
to disclose

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