What is the initial treatment for a patient presenting with torticollis (wry neck)?

Initial Treatment for Torticollis (Wry Neck) in Adults

The initial treatment for adult torticollis depends critically on distinguishing between benign muscular causes and serious underlying pathology—begin with a focused history and physical examination to identify red flags for malignancy, infection, or neurologic disease, then proceed with observation and physical therapy for benign muscular torticollis while urgently investigating any concerning features. 1, 2, 3

Immediate Risk Stratification

The first priority is determining whether this represents benign muscular torticollis versus a dangerous underlying condition:

Red Flags Requiring Urgent Workup

• Malignancy concerns: Mass present ≥2 weeks, age >40 years, tobacco/alcohol use, prior head/neck cancer, associated hoarseness, dysphagia, weight loss, or hemoptysis 1, 4
• Infectious causes: Recent upper respiratory infection, sinusitis, otomastoiditis, cervical adenitis, retropharyngeal abscess, or fever 5
• Neurologic/skeletal pathology: Trauma history, neurologic deficits, severe pain with paresthesias, or signs of atlantoaxial subluxation 5, 6

Physical Examination Findings

For benign congenital muscular torticollis (CMT): Cord-like sternocleidomastoid muscle, head tilted toward affected side with chin rotated away, facial asymmetry present since childhood, absence of head tremor, and no sensory tricks 7, 2

High-risk features: Fixed mass >1.5 cm, firm consistency, fixation to adjacent tissues, ulceration, or tender cervical lymphadenopathy 1, 4

Initial Management Algorithm

For Benign Muscular Torticollis (Low-Risk Patients)

Conservative treatment is first-line and highly effective, especially when initiated early:

• Physical therapy: Stretching exercises targeting the sternocleidomastoid muscle, with or without bracing 2
• Observation period: Most cases respond to conservative management within weeks to months 2, 3
• Botulinum toxin injections: Consider for resistant cases not responding to physical therapy—this has shown long-lasting benefit in adult CMT patients 7
• Structured follow-up: Document specific follow-up plan and educate patients on warning signs requiring re-evaluation 1

For High-Risk Patients (Red Flags Present)

Do NOT initiate empiric treatment—proceed immediately with diagnostic workup:

• Imaging: CT neck with contrast or MRI with contrast to evaluate for mass lesions, abscess, or structural abnormalities 1, 4, 5
• Avoid empiric antibiotics: Unless clear signs of bacterial infection are present, as most adult neck masses are neoplastic, not infectious 1, 4
• Urgent specialist referral: Direct communication with otolaryngology or neurosurgery depending on suspected etiology 1

Critical Management Pitfalls

Never assume a neck mass or torticollis is benign without thorough evaluation—missing nonmuscular torticollis could be life-threatening 2, 3

Do not perform open biopsy before completing imaging and attempting fine-needle aspiration if a mass is identified 1

Avoid prolonged observation in patients with red flags—delayed diagnosis of malignancy directly worsens prognosis and tumor stage 4

Surgical Considerations

Surgery is reserved for specific scenarios:

• Persistent CMT after age 1 year: Sternocleidomastoid muscle lengthening may improve range of motion but not necessarily facial asymmetry 2
• Adult longstanding torticollis with pain/paresthesias: Two-stage bipolar surgical division with gradual correction in halo-vest apparatus can achieve excellent results 6
• Atlantoaxial subluxation: May require stabilization if identified on imaging 5

Timeline for Reassessment

• Low-risk patients: Reassess within 2-4 weeks to monitor response to conservative treatment 1
• Patients treated with antibiotics for suspected infection: Reassess within 2 weeks; if not completely resolved, proceed with malignancy workup 4
• High-risk patients: Immediate imaging and specialist consultation without delay 1, 4