Torticollis
The medical term for a stiff neck with the head tilted to one side is torticollis. This describes a clinical presentation where the head is laterally tilted with chin rotation toward the opposite side of the tilt 1, 2.
Understanding the Term
Torticollis literally refers to a "twisted neck" and represents a symptom rather than a single disease entity 2. The condition is characterized by:
- Lateral head tilt toward one side 1
- Chin rotation toward the opposite side of the tilt 1, 2
- Neck stiffness with restricted range of motion 3
Age-Dependent Differential Diagnosis
The underlying causes differ significantly based on patient age 1:
In Infants
Congenital muscular torticollis is the most common cause, resulting from sternocleidomastoid muscle contracture 1, 3. Other infant-specific causes include:
- Benign paroxysmal torticollis (BPT): Recurrent episodes of painless head postures alternating from side to side, typically presenting before 3 months of age 4
- Sandifer syndrome: Head tilt associated with gastroesophageal reflux, particularly after eating 4
- Ocular torticollis: Secondary to eye muscle weakness 1
In Older Children and Adults
- Atlantoaxial rotatory displacement: Most frequently from trauma or oropharyngeal inflammation 1
- Cervical dystonia (spasmodic torticollis): Sustained involuntary muscle contractions causing neck rotation, more common in adolescents and adults 1, 5
- Skew deviation with ocular tilt reaction: Associated with vestibular or posterior fossa pathology, presenting with head tilt toward the hypotropic eye 4
Critical Distinction: Muscular vs. Nonmuscular
It is essential to differentiate benign muscular torticollis from potentially life-threatening nonmuscular causes 3. Red flags requiring urgent evaluation include:
- Associated neurological symptoms: Headaches, vomiting, altered mental status 1
- Multiple cranial nerve palsies: Suggesting cavernous sinus or brainstem pathology 6
- Acute onset with diplopia: May indicate posterior circulation stroke or vestibular pathology 7
- Pupil involvement: Requires urgent neuroimaging to exclude aneurysm 6, 8
Initial Evaluation Approach
When evaluating torticollis, clinicians should:
- Perform complete physical and neurologic examination looking for associated findings such as ptosis, extraocular movement limitations, or other cranial nerve deficits 6, 3
- Obtain cervical spine radiographs to rule out bony abnormalities 3
- Consider urgent MRI of brain and brainstem if nonmuscular causes are suspected, particularly with acute onset, neurological signs, or diplopia 4, 7
A common pitfall is missing nonmuscular torticollis, which could represent serious underlying pathology such as posterior fossa tumors, increased intracranial pressure, or brainstem lesions 1, 3.