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