Acquired torticollis in children
- Charles G Macias, MD, MPH
Charles G Macias, MD, MPH
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Vanthaya Gan, MD
Vanthaya Gan, MD
- Clinical Professor of Pediatrics
- University of Texas Southwestern Medical Center
- Section Editors
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- William Phillips, MD
William Phillips, MD
- Section Editor — Pediatric Orthopedics
- Professor of Pediatrics and Orthopedics
- Baylor College of Medicine
- Glenn C Isaacson, MD, FAAP
Glenn C Isaacson, MD, FAAP
- Section Editor — Pediatric Otolaryngology
- Professor, Department of Otolaryngology, Head and Neck Surgery and Pediatrics
- Lewis Katz School of Medicine at Temple University
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
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 . 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".)
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 .
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:
- Ozuah, P. Torticollis. In: Primary Pediatric Care, 4th, Hoekelman, RA (Eds), Mosby, St. Louis 2001. p.1282.
- Tomczak KK, Rosman NP. Torticollis. J Child Neurol 2013; 28:365.
- Torticollis. In: Signs and Symptoms in Pediatrics, 3rd, Tunnessen WW, Roberts KB (Eds), Lippincot Williams & Wilkins, Philadelphia 1999. p.353.
- Bredenkamp JK, Maceri DR. Inflammatory torticollis in children. Arch Otolaryngol Head Neck Surg 1990; 116:310.
- Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
- Visudhiphan P, Chiemchanya S, Somburanasin R, Dheandhanoo D. Torticollis as the presenting sign in cervical spine infection and tumor. Clin Pediatr (Phila) 1982; 21:71.
- Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.
- Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
- Fok WM, Sun LK, Wong NM, et al. Spontaneous spinal epidural haematoma in a 15-month-old boy presenting with a wry neck: a case report. J Orthop Surg (Hong Kong) 2007; 15:373.
- Sankar J, Srinivasan A, Ramakrishnan V, Balasubramaniam C. An unusual cause of acute torticollis. Clin Pediatr (Phila) 2009; 48:784.
- Cuvelier GD, Davis JH, Purves EC, Wu JK. Torticollis as a sign of cervico-thoracic epidural haematoma in an infant with severe haemophilia A. Haemophilia 2006; 12:683.
- The neck. In: Pediatric Diagnosis: Interpretation of Symptoms and Signs in Children and Adolescents, 6th, Green M (Ed), WB Saunders, Philadelphia 1998. p.63.
- Caputo AR, Mickey KJ, Guo S, et al. The sit-up test: an alternate clinical test for evaluating pediatric torticollis. Pediatrics 1992; 90:612.
- Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
- Gupta AK, Roy DR, Conlan ES, Crawford AH. Torticollis secondary to posterior fossa tumors. J Pediatr Orthop 1996; 16:505.
- Turgut M, Akalan N, Bertan V, et al. Acquired torticollis as the only presenting symptom in children with posterior fossa tumors. Childs Nerv Syst 1995; 11:86.
- Extremera VC, Alvarez-Coca J, Rodríguez GA, et al. Torticollis is a usual symptom in posterior fossa tumors. Eur J Pediatr 2008; 167:249.
- Pharisa C, Lutz N, Roback MG, Gehri M. Neck complaints in the pediatric emergency department: a consecutive case series of 170 children. Pediatr Emerg Care 2009; 25:823.
- Muñiz AE, Belfer RA. Atlantoaxial rotary subluxation in children. Pediatr Emerg Care 1999; 15:25.
- Brisson P, Patel H, Scorpio R, Feins N. Rotary atlanto-axial subluxation with torticollis following central-venous catheter insertion. Pediatr Surg Int 2000; 16:421.
- Gourin CG, Kaper B, Abdu WA, Donegan JO. Nontraumatic atlanto-axial subluxation after retropharyngeal cellulitis: Grisel's syndrome. Am J Otolaryngol 2002; 23:60.
- Berry DS, Moriarty RA. Atlantoaxial subluxation related to pharyngitis: Grisel's syndrome. Clin Pediatr (Phila) 1999; 38:673.
- Sia KJ, Tang IP, Kong CK, Nasriah A. Grisel's syndrome: a rare complication of tonsillectomy. J Laryngol Otol 2012; 126:529.
- Dagtekin A, Kara E, Vayisoglu Y, et al. The importance of early diagnosis and appropriate treatment in Grisel's syndrome: report of two cases. Turk Neurosurg 2011; 21:680.
- Ortega-Evangelio G, Alcon JJ, Alvarez-Pitti J, et al. Eponym : Grisel syndrome. Eur J Pediatr 2011; 170:965.
- Deichmueller CM, Welkoborsky HJ. Grisel's syndrome--a rare complication following "small" operations and infections in the ENT region. Eur Arch Otorhinolaryngol 2010; 267:1467.
- Onerci M, Ogretmenoglu O, Ozcan OE. Atlantoaxial subluxation after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1997; 116:271.
- Derkay CS, Kenna MA, Pang D. Refractory torticollis: an uncommon complication of adenotonsillectomy. Int J Pediatr Otorhinolaryngol 1987; 14:87.
- Torticollis. In: Essentials of Musculoskeletal Care, 2nd, Greene WB (Ed), American Academy of Orthopedic Surgeons, Rosement 2001. p.719.
- Tom LW, Rossiter JL, Sutton LN, et al. Torticollis in children. Otolaryngol Head Neck Surg 1991; 105:1.
- Atlantoaxial instability in Down syndrome: subject review. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics 1995; 96:151.
- Pueschel SM, Scola FH. Atlantoaxial instability in individuals with Down syndrome: epidemiologic, radiographic, and clinical studies. Pediatrics 1987; 80:555.
- Hall DE, Boydston W. Pediatric neck injuries. Pediatr Rev 1999; 20:13.
- Herman MJ, Pizzutillo PD. Cervical spine disorders in children. Orthop Clin North Am 1999; 30:457.
- Ruge JR, Sinson GP, McLone DG, Cerullo LJ. Pediatric spinal injury: the very young. J Neurosurg 1988; 68:25.
- Herzka A, Sponseller PD, Pyeritz RE. Atlantoaxial rotatory subluxation in patients with Marfan syndrome. A report of three cases. Spine (Phila Pa 1976) 2000; 25:524.
- Li MF, Chiu PC, Weng MJ, Lai PH. Atlantoaxial instability and cervical cord compression in Morquio syndrome. Arch Neurol 2010; 67:1530.
- Msall ME, Reese ME, DiGaudio K, et al. Symptomatic atlantoaxial instability associated with medical and rehabilitative procedures in children with Down syndrome. Pediatrics 1990; 85:447.
- Chaudhry V, Sturgeon C, Gates AJ, Myers G. Symptomatic atlantoaxial dislocation in Down's syndrome. Ann Neurol 1987; 21:606.
- Godard J, Jacquet G, Bonneville JF, et al. [Torticollis and C1-C2 rotation subluxation. Apropos of a case. The value of a dynamic scanner and of a 3-dimensional scanner]. J Neuroradiol 1994; 21:223.
- Phillips WA, Hensinger RN. The management of rotatory atlanto-axial subluxation in children. J Bone Joint Surg Am 1989; 71:664.
- Subach BR, McLaughlin MR, Albright AL, Pollack IF. Current management of pediatric atlantoaxial rotatory subluxation. Spine (Phila Pa 1976) 1998; 23:2174.
- Epps HR, Salter RB. Orthopedic conditions of the cervical spine and shoulder. Pediatr Clin North Am 1996; 43:919.
- Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am 1977; 59:37.
- Young TL, Weis JR, Summers CG, Egbert JE. The association of strabismus, amblyopia, and refractive errors in spasmus nutans. Ophthalmology 1997; 104:112.
- Drigo P, Carli G, Laverda AM. Benign paroxysmal torticollis of infancy. Brain Dev 2000; 22:169.
- Hanukoglu A, Somekh E, Fried D. Benign paroxysmal torticollis in infancy. Clin Pediatr (Phila) 1984; 23:272.
- Al-Twaijri WA, Shevell MI. Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatr Neurol 2002; 26:365.
- Deonna T, Martin D. Benign paroxysmal torticollis in infancy. Arch Dis Child 1981; 56:956.
- Kimura S, Nezu A. Electromyographic study in an infant with benign paroxysmal torticollis. Pediatr Neurol 1998; 19:236.
- Del Cuore F. [Benign paroxysmal torticollis in childhood]. Pediatr Med Chir 1997; 19:69.
- Cataltepe SU, Barron TF. Benign paroxysmal torticollis presenting as "seizures" in infancy. Clin Pediatr (Phila) 1993; 32:564.
- Balslev T, Flarup M, Ostergaard JR, Haslam RH. [Benign paroxysmal torticollis. Recurrent involuntary twisting of the head in infants and young children]. Ugeskr Laeger 1998; 160:5365.
- Chaves-Carballo E. Paroxysmal torticollis. Semin Pediatr Neurol 1996; 3:255.
- Bratt HD, Menelaus MB. Benign paroxysmal torticollis of infancy. J Bone Joint Surg Br 1992; 74:449.
- Murphy WJ, Gellis SS. Torticollis with hiatus hernia in infancy. Sandifer syndrome. Am J Dis Child 1977; 131:564.
- Deskin RW. Sandifer syndrome: a cause of torticollis in infancy. Int J Pediatr Otorhinolaryngol 1995; 32:183.
- Werlin SL, D'Souza BJ, Hogan WJ, et al. Sandifer syndrome: an unappreciated clinical entity. Dev Med Child Neurol 1980; 22:374.
- Causey AL, Evans OB, Lewis-Abney K. Intervertebral disk calcification: an unusual cause of acquired torticollis in childhood. Pediatr Emerg Care 1996; 12:356.
- Oliveira T, Barbosa C, Neves E, et al. [Cervical spondylodiscitis in an infant]. An Esp Pediatr 2000; 52:398.
- Kombogiorgas D, Hussain I, Sgouros S. Atlanto-axial rotatory fixation caused by spontaneous intracerebral haemorrhage in a child. Childs Nerv Syst 2006; 22:1182.
- Staheli LT. Spine and neck. In: Fundamentals of Pediatric Orthopedics, 2nd, Lippincott Raven, Philadelphia 1998. p.73.
- Straussberg R, Harel L, Amir J. Pseudotumor cerebri manifesting as stiff neck and torticollis. Pediatr Neurol 2002; 26:225.
- Haque S, Bilal Shafi BB, Kaleem M. Imaging of torticollis in children. Radiographics 2012; 32:557.
- Lustrin ES, Karakas SP, Ortiz AO, et al. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics 2003; 23:539.
- LIFE-THREATENING CAUSES
- Retropharyngeal abscess
- Suppurative jugular thrombophlebitis (Lemierre syndrome)
- Cervical spine injury
- Spinal epidural hematoma
- Central nervous system tumor
- COMMON CAUSES
- Muscle injury or inflammation
- Acute infections
- Atlantoaxial rotary subluxation
- - Clinical manifestations and diagnosis
- - Management
- OTHER CAUSES
- Ocular torticollis
- - Spasmus nutans
- Benign paroxysmal torticollis
- Dystonic reaction
- Sandifer syndrome
- CLINICAL PRESENTATION AND APPROACH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS