Torticollis in children is a posture rather than a diagnosis. Although most cases encountered in the emergency department represent a benign, self-limited muscular spasm of the sternocleidomastoid or trapezius and resolve over days, a meaningful subset heralds serious pathology involving the craniocervical junction, deep neck spaces, or posterior fossa.¹ An emergency department approach that is structured, risk-factor aware, and imaging-savvy can safely distinguish uncomplicated muscular torticollis from conditions requiring urgent specialty intervention.² This column offers a practical diagnostic and management framework so that you can pick up one of the often-elusive limb or life-threatening diagnoses on your next shift.

Differential Diagnosis Anchored to Clinical Risk

Three “can’t-miss” categories warrant deliberate consideration. Atlantoaxial subluxation/atlanto-axial rotatory fixation (AAS/AARF) arises from ligamentous laxity or osseous anomalies and may follow minor trauma, congenital connective-tissue disorders, or postoperative inflammatory states (Grisel syndrome).³ Children with trisomy 21 (Down syndrome), Marfan syndrome, juvenile idiopathic arthritis, or rarer syndromes (e.g., Klippel-Feil, Morquio) carry elevated risk.⁴ A careful history that elicits recent ENT surgery and a focused screen for myelopathic symptoms is essential.

Deep neck space infection — most notably retropharyngeal abscess (RPA) — often presents between ages two and four, with prominent unwillingness to move the neck and limitation of extension, frequently accompanied by fever, dysphagia, odynophagia, drooling, or stridor in more advanced cases.⁵ Osteomyelitis/discitis of the cervical spine is rarer but should be considered when midline bony tenderness is present. Lemierre syndrome (septic thrombophlebitis of the internal jugular vein after oropharyngeal infection) is uncommon but important; look for focal tenderness, swelling, or induration along the jugular chain in a toxic-appearing child.⁶

Central nervous system lesions involving the posterior fossa or high cervical cord can initially manifest with a pinkless head tilt. Approximately half of pediatric brain tumors arise in the posterior fossa. Torticollis may precede other neurologic signs in a non-trivial proportion, with contemporary series and expert synthesis citing up to 20 percent of posterior fossa tumors presenting with torticollis.⁷ A normal passive range of cervical motion and lack of neck tenderness must not reassure when other posterior fossa symptoms or subtle cranial nerve deficits are present.⁸

Bedside Discriminators: History and Focused Examination

Risk stratification begins with three targeted lines of inquiry. First, screen for AAS risk: trauma (often minor), congenital hypermobility or inflammatory conditions, and recent head/neck surgery.⁴ Second, elicit infectious red flags including fever, odynophagia, drooling, stridor, and focal jugular-chain tenderness.⁵ Third, probe neurologic symptoms — headache (especially morning predominant headache), vomiting, gait disturbance, ataxia, and focal deficits or cranial nerve palsies.⁹ On examination, a key clinical clue is that in uncomplicated muscular torticollis, the head typically tilts toward the spastic sternocleidomastoid (SCM) with the chin rotated contralaterally, whereas in AAS/AARF the head frequently tilts away from the affected side; the contralateral SCM (on the chin side) may be tighter and tender as it “attempts” to correct the deformity.⁴ This bedside sign should heighten concern for craniocervical instability and lower the threshold for immobilization and advanced imaging.¹⁰

Painless torticollis demands particular caution. When the head tilt is not painful and passive range of motion is relatively preserved, prioritize a central nervous system (CNS) search rather than a muscular diagnosis. Incorporate a complete neurologic exam, including ocular alignment and cranial nerves IV and VI, as head tilt can be a compensatory posture for diplopia.⁹

Imaging Strategy: When Plain Films Suffice and When CT or MRI Is Required

For children with low pretest probability of AAS, antero-posterior (AP) open-mouth odontoid and lateral cervical radiographs can serve as a first-line screen. The atlantodental interval (ADI) — the distance between the anterior arch of C1 and the odontoid — should not exceed roughly 4-5 mm in young children, acknowledging technique dependence and increased laxity with flexion. Values above this range are suspicious for transverse ligament injury.¹¹ However, radiographs may be normal in rotatory malalignment. When clinical suspicion is moderate to high, or when neurologic findings, significant risk factors, or equivocal films are present, CT is the diagnostic gold standard for AARF/AAS and should not be delayed. Dynamic CT in maximal rotation can characterize chronic fixation.¹¹ MRI adds value when there is concern for cord compression, ligamental disruption, or associated infection.¹²

For suspected retropharyngeal abscess, a lateral neck radiograph may show prevertebral soft-tissue widening and can be a useful screen; contrast-enhanced CT of the neck is typically definitive, delineates collections, and expedites operative planning with ENT.¹² For suspected posterior fossa or high cervical cord pathology, MRI of brain and cervical spine is preferred; if MRI is not immediately accessible in a deteriorating child, CT is an acceptable bridge while arranging definitive imaging .¹¹ Throughout any AAS work-up, maintain gentle immobilization and avoid forced rotation or range-of-motion testing until stability is clarified.³

Management Pathways Tailored to Etiology

Children with uncomplicated muscular torticollis generally respond to oral analgesia, local heat application, and gradual return to comfort-guided range of motion. A brief period in a soft collar can be used for comfort but should not delay reassessment. Persistent symptoms beyond one week, or clinical non-response to supportive measures, argues against a benign muscular etiology and should trigger re-evaluation and imaging.²

For AAS/AARF, treat the neck as potentially unstable. Employ gentle immobilization, consult pediatric spine/neurosurgery early, and obtain a CT. Many patients without neurologic deficit improve with traction, anti-inflammatory measures, and collar immobilization. Refractory, recurrent, or neurologically complicated cases may require reduction under anesthesia or operative stabilization.³ Children with trisomy 21 merit special vigilance: routine screening radiographs are no longer recommended by the American Academy of Pediatrics, but clinicians and families should be counseled to monitor for symptoms and signs of myelopathy (neck pain, torticollis, loss of motor skills, gait change, or bowel/bladder dysfunction) and to seek prompt evaluation when present.¹²

Management of RPA and related deep neck infections begins with airway assessment and early ENT involvement. Initiate broad-spectrum intravenous antibiotics according to local antimicrobiogram, maintain a low threshold for contrast CT to define deep collections, and arrange timely drainage when indicated.¹³ In Lemierre syndrome, cover Fusobacterium necrophorum and gram-negative organisms empirically, image the neck veins (ultrasound or CT venography), and admit for intravenous therapy and monitoring. Be attentive to pulmonary septic emboli.¹⁴

For suspected CNS lesions, do not be reassured by a comfortable neck. Expedite neuroimaging and neurosurgical consultation when torticollis is painless or accompanied by posterior fossa symptoms, ocular misalignment, or gait disturbance. Recognize that torticollis may precede more obvious neurologic findings.¹⁵

Disposition and Follow-Up

Well-appearing children with improving muscular torticollis, reliable caregivers, and no red flags can be discharged safely with clear instructions regarding analgesia, gentle mobility, and specific return precautions: especially fever, drooling, stridor, progressive vomiting or headache, gait change, focal weakness, or persistence beyond one week. Admission is appropriate for suspected or confirmed AAS/AARF, any neurologic deficit, signs of airway compromise or confirmed deep neck space infection, or when diagnostic imaging or specialist consultation cannot be completed safely as an outpatient.¹⁶

Key Take-Home Points

A risk-factor-anchored approach improves diagnostic yield and reduces unnecessary imaging. The “tilt away” sign is a useful discriminator for AAS/AARF at the bedside. The atlantodental interval provides a radiographic clue but cannot exclude rotatory malalignment. CT remains the emergency department gold standard when suspicion is meaningful. RPA typically affects young children and limits neck extension, contrast CT guides surgical drainage. Painless torticollis should default to a CNS search. Above all, persistence beyond one week or failure to respond to supportive measures warrants re-evaluation. With these key points in mind, the next time you are faced with child who presents with torticollis, you will have the tools to sort through the differential diagnosis, make imaging, treatment and disposition decisions, and potentially save the life or limb of a child.

Many thanks to Dr. Deborah Schonfeld, the guest expert on the EM Cases podcast that inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.

References

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