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.