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