What is the Differential Diagnosis of Torticollis?

Patient Presentation
An 8-year-old female came to clinic with acute onset of torticollis since that morning.
The previous night she said that she didn’t feel well but did not have a fever. She was given ibuprofen and slept through the night.
In the morning, she initially acted normal but during breakfast she started complaining about her neck being sore.
She was sent to school. The school called because she now was tilting her head.
The past medical history and family history was non-contributory.
The review of systems showed no fever, chills, nausea, emesis, sore throat, ear pain, respiratory problems, difficulty swallowing or trauma. She said that she had a runny nose and felt a little achy.
The pertinent physical exam revealed an afebrile female with normal vital signs and growth parameters.
Her eyes and ears were normal.
Her nose revealed clear discharge and a mildly erythematous pharynx without tonsillar enlargement, exudate or palatal petechiae. Her retropharynx appeared normal.
She was holding her forehead tilted to the right and chin tilted to the left. Her chin was also turned slightly toward the left shoulder. She had some shoddy anterior cervical adenopathy bilaterally.
She complained of muscle pain over the left sternocleidomastoid muscle and trapezius muscles. She was able to place her head in a neutral position and was able to turn her head and chin to the right to about 30 degrees and put her ear to her right shoulder to about 20 degrees.
This limitation was because of muscle pain. The neurological exam and the rest of her examination were normal.
The diagnosis of torticollis most likely due to viral myositis was made.
Her mother was told to continue to monitor her as she should improve in the next few days, to use anti-inflammatory medications and provide symptomatic relief with warm packs.
They were to call if the symptoms worsened particularly if there was any significant increase in pain or respiratory problems.

Torticollis or wry neck is a clinical sign and symptom where there is a lateral head tilt and chin rotation toward the opposite side.
In infants, congenital torticollis caused by a contracture of the sternocleidomastoid muscle and is the most common cause. It is usually successfully treated with stretching exercises.
Common causes of acquired torticollis in older children include cervical adenitis and viral myositis.

History and physical examination are important in evaluating the potential causes.
A definitive history of trauma with obvious muscle spasm in the neck and shoulder girdle and normal neurological examination would most likely warrant stretching and anti-inflammatory medication.
A patient with obvious viral syndrome complaints and a normal neurological examination and no tonsillar or retropharyngeal abnormalities again most likely would warrant anti-inflammatory medications and symptomatic warm packs.
A patient with worsening symptoms or any abnormalities on neurological or airway examination warrants a fuller evaluation for possible abscess or tumor.
Imaging evaluation such as a computed tomography of the head and neck may be helpful. An ultrasound of the neck may also be helpful in differentiating cervical adenitis from a cervical abscess.

Learning Point
The differential diagnosis of torticollis includes:

  • Muscle
    • Congenital torticollis – i.e. sternocleidomastoid muscle contracture
    • Dystonia
    • Myositis ossificans progressiva
    • Poliomyelitis
    • Viral myositis (also called ‘rheumatic’ stiff neck)
  • Joints and Vertebrae
    • Arthritis, juvenile
    • Klippel-Feil syndrome
    • Odontoid anomaly
    • Osteitis
    • Other abnormalities of the upper thoracic spine
    • Scoliosis
    • Sprengel’s deformity (i.e. high scapular position)
    • Trauma – subluxation of atlanto-axial joint, strain
    • Tumor
  • Soft tissue
    • Abscess – tonsillar, retropharyngeal
    • Adenitis, cervical
  • Central Nervous System
    • Posterior fossa tumor
    • AV malformation
    • Other infection of the central nervous system
  • Drugs
  • Eye – ocular torticollis (i.e. caused by eye muscle weakness)
  • Ear – vestibular disturbance
  • Esophagus and Oropharynx
    • Grisel’s syndrome (i.e. inflammation of the oropharynx)
    • Sandifer’s syndrome (i.e. caused by gastroesophageal reflux)
  • Psychological
    • Habit
    • Somatization
    • Tic

Questions for Further Discussion
1. What are the most common organisms that cause cervical adenitis?
2. What are the treatment options for congenital torticollis if stretching does not work?
3. What are the potential complications of congenital torticollis if it is not treated?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Dystonia and Neck Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:252-254.

Herman MJ.

Torticollis in infants and children: common and unusual causes.
Instr Course Lect. 2006;55:647-53.

Do TT.

Congenital muscular torticollis: current concepts and review of treatment.
Curr Opin Pediatr. 2006 Feb;18(1):26-9.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    December 15, 2008