Acute Torticollis

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Emergent management of torticollis can pose a challenge to the emergency physician owing to the fact that the condition can be acute or chronic, congenital or acquired, and idiopathic or secondary to trauma or disease. Moreover, the onset of torticollis can occur at any age.

In addition, laboratory studies are not particularly helpful and are dependent on underlying disorder, although they are useful if infection is suspected.

In prehospital treatment of acute torticollis, ensure a patent airway and perform cervical spine immobilization/precautions for patients with a history of trauma.

Plain cervical radiographs, computed tomography (CT) scans, or magnetic resonance imaging (MRI) scans of the cervical spine may be useful to evaluate for bony trauma, suspected C1-C2 subluxation, congenital bony abnormalities, or osteomyelitis. (See the image below.) ^[1]

Employing CT scanning or MRI of the neck may be useful for evaluation of suspected abscesses, deep space infections, or masses, while using either of these modalities to image the brain may be useful to exclude suspected tumors. ^[2]

Emergency department physicians should not diagnose idiopathic spasmodic torticollis if the patient has acute torticollis; consider other causes.

Unusual cervical disk herniation or bony subluxation, on occasion, causes acute wryneck or torticollis.

Emergent diagnoses of retropharyngeal abscess, epiglottitis, and spinal epidural abscesses and hematomas should always be considered. ^{[3, 4]} Pediatric patients should have a complete eye examination. ^[5]

Patients with acute traumatic torticollis should have immediate cervical spine immobilization before further evaluation. Patients with respiratory compromise, stridor, or drooling should have emergent evaluation and management.

Emergent diagnoses of retropharyngeal abscess, epiglottitis, and spinal epidural hematomas should always be considered.

Treatment of torticollis is generally supportive and includes analgesics, benzodiazepines, anticholinergics, heat, massage, and stretching exercises. Most cases of torticollis, including congenital muscular torticollis resolve spontaneously.

Reversible causes of torticollis should be identified and treated accordingly. Appropriate antibiotics should be given for infectious causes. Drug-induced torticollis is treated with diphenhydramine, benztropine, or benzodiazepines.

Treatment of atlantoaxial subluxation depends on severity and duration and ranges from simple analgesia to cervical traction and immobilization to surgery. ^{[6, 7]} Antireflux therapy is indicated for children with Sandifer syndrome.

Emergent specialist consultation is necessary for life-threatening diagnoses, including retropharyngeal abscess, epiglottitis, spinal epidural abscesses and hematomas, severe cervical fractures, and dislocations.

Appropriate follow-up depends on the underlying disease process. Infants with congenital muscular torticollis should be monitored at 2- to 4-week intervals. Refer most patients with prolonged symptoms suggestive of idiopathic spasmodic torticollis to a neurologist for follow-up. Fixed deformities in children may require surgical referral.

Drugs of choice for treatment of torticollis include analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen, opiates), benzodiazepines, anticholinergics, and local intramuscular injections of botulinum toxin (BOTOX®). Emergency physicians, as standard practice, do not administer BOTOX® injections; tertiary referral centers perform most injections. ^{[8, 9, 10]}

Drugs of choice for dystonic reactions secondary to medication include diphenhydramine, benztropine, and benzodiazepines.

Lee YT, Park JW, Lim M, Yoon KJ, Kim YB, et al. A Clinical Comparative Study of Ultrasound-Normal Versus Ultrasound-Abnormal Congenital Muscular Torticollis. PM R. 2015 Aug 7. [Medline].

Kim JW, Kim SH, Yim SY. Quantitative analysis of magnetic resonance imaging of the neck and its usefulness in management of congenital muscular torticollis. Ann Rehabil Med. 2015 Apr. 39 (2):294-302. [Medline].

Hasegawa J, Tateda M, Hidaka H, Sagai S, Nakanome A, Katagiri K. Retropharyngeal abscess complicated with torticollis: case report and review of the literature. Tohoku J Exp Med. 2007 Sep. 213(1):99-104. [Medline].

Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol. 1997 Dec. 111(12):1183-5. [Medline].

Nichter S. A Clinical Algorithm for Early Identification and Intervention of Cervical Muscular Torticollis. Clin Pediatr (Phila). 2015 Aug 24. [Medline].

Sobolewski BA, Mittiga MR, Reed JL. Atlantoaxial rotary subluxation after minor trauma. Pediatr Emerg Care. 2008 Dec. 24(12):852-6. [Medline].

Tonomura Y, Kataoka H, Sugie K, Hirabayashi H, Nakase H, Ueno S. Atlantoaxial rotatory subluxation associated with cervical dystonia. Spine (Phila Pa 1976). 2007 Sep 1. 32(19):E561-4. [Medline].

Costa J, Espirito-Santo C, Borges A, et al. Botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev. 2005 Jan 25. CD004315. [Medline].

Denislic M, Pirtosek Z, Vodusek DB, Zidar J, Meh D. Botulinum toxin in the treatment of neurological disorders. Ann N Y Acad Sci. 1994 Mar 9. 710:76-87. [Medline].

Truong D, Duane DD, Jankovic J, Singer C, Seeberger LC, Comella CL, et al. Efficacy and safety of botulinum type A toxin (Dysport) in cervical dystonia: results of the first US randomized, double-blind, placebo-controlled study. Mov Disord. 2005 Jul. 20(7):783-91. [Medline].

Preeti Dalawari, MD, MSPH, FAAEM, FACEP Associate Professor, Director of Research, Department of Surgery, Division of Emergency Medicine, St Louis University School of Medicine; Attending Physician in Emergency Medicine, St Louis University Hospital

Preeti Dalawari, MD, MSPH, FAAEM, FACEP is a member of the following medical societies: Academy for Women in Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ryan J Haskamp, MD Resident Physician, Department of Emergency Medicine, St Louis University School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Christopher M McStay, MD Assistant Professor, Department of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center

Christopher M McStay, MD is a member of the following medical societies: American College of Emergency Physicians, Wilderness Medical Society

Disclosure: Nothing to disclose.

Kevin Tao, MD Attending Physician, Emergency Department, MacNeal Hospital

Kevin Tao, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acute Torticollis

Research & References of Acute Torticollis|A&C Accounting And Tax Services
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