What are the treatment options for acute torticollis in children?

Treatment of Acute Torticollis in Children

For acute torticollis in children, initiate multimodal analgesia with NSAIDs (ibuprofen or acetaminophen) combined with heat therapy and gentle stretching exercises, while simultaneously ruling out serious underlying causes through targeted clinical assessment. 1

Immediate Management Strategy

Pain Control and Muscle Relaxation

• Administer NSAIDs as first-line therapy for pain control and inflammation reduction 1
• Acetaminophen or ibuprofen should be given during the first 24-48 hours for additional pain relief 1
• Apply heat therapy to the affected neck muscles to relax muscle tension and improve local blood circulation 1
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain conditions 1

Physical Interventions

• Implement gentle stretching exercises to gradually restore normal cervical range of motion 1
• Ensure proper head and neck positioning during rest and sleep to prevent symptom worsening 1
• Manual cervical stretching is particularly effective for congenital muscular torticollis in infants 2

Severe Cases

• For severe pain with significant inflammation, consider a short course of oral corticosteroids to rapidly reduce inflammation 1

Critical Differential Diagnosis Assessment

Before treating as simple muscular torticollis, you must systematically exclude serious pathology 3, 4:

Red Flags Requiring Urgent Evaluation

• Progressive neurological symptoms or signs of spinal cord compression mandate immediate imaging and specialist referral 1
• Fever, severe pain, or systemic illness suggest infectious causes (retropharyngeal abscess, cervical adenitis, pyogenic spondylitis) 4
• Headaches, vomiting, or intermittent neurologic symptoms may indicate posterior fossa tumors 2
• Recent trauma or upper respiratory infection raises concern for atlantoaxial rotatory subluxation 4, 5

Specific Etiologies to Consider

• Inflammatory causes are most common in acute presentations: upper respiratory infection, sinusitis, otomastoiditis, cervical adenitis, or retropharyngeal abscess/cellulitis 4
• Atlantoaxial rotatory subluxation presents with the classic "cock-robin" position (head tilted to one side, chin rotated to opposite side) with diminished range of motion, often following minor trauma 5
• Ocular torticollis from eye muscle weakness should be ruled out per American Academy of Ophthalmology recommendations 1
• Sandifer's syndrome from gastroesophageal reflux is an unusual but important consideration in infants 2

Physical Therapy Protocol

Supervised Interventions

• Gentle manual therapy techniques including mobilization and trigger point therapy reduce muscle tension 1
• Supervised postural exercises and stretching with or without manual trigger point therapy have demonstrated benefit 1

Home Exercise Program

• Implement home stretching and strengthening exercises focusing on neck muscles 1
• For congenital muscular torticollis in infants, manual cervical stretching is usually effective, especially when started within the first year of life 6

When to Escalate Care

Imaging Indications

• Order imaging if no improvement occurs with initial conservative management 1
• Cervical spine radiographs are essential to rule out bony abnormalities 6
• CT scanning (especially dynamic studies) may be needed to verify atlantoaxial subluxation 5
• MRI of brain and neck is no longer considered cost-effective or necessary for congenital muscular torticollis 6

Specialist Referral

• Refer to ophthalmology if ocular causes are suspected 1
• Orthopedic or neurosurgical consultation is needed for atlantoaxial subluxation, especially if severe or long-standing 5
• ENT evaluation is warranted for suspected infectious causes (retropharyngeal abscess, cervical adenitis) 4

Common Pitfalls to Avoid

• Do not assume all torticollis is benign muscular tightness - missing nonmuscular causes could be life-threatening 6
• Do not perform sternocleidomastoid muscle release without first ruling out congenital anomalies of the occipital condyles and upper cervical spine 2
• Do not delay imaging in children with fever, neurologic symptoms, or failure to improve with conservative treatment 4
• Four of 26 children with inflammatory torticollis had atlantoaxial subluxation as a complication, emphasizing the need for thorough evaluation 4

Age-Specific Considerations

Infants

• Congenital muscular torticollis with sternocleidomastoid contracture is the most common cause 2
• Benign paroxysmal torticollis presents as recurrent episodes of abnormal, painless head postures, typically before 3 months of age 1
• Physical therapy is highly effective when initiated early, with increased surgical rates if treatment starts after age 1 year 6

Older Children and Adolescents

• Atlantoaxial rotatory displacement from trauma or oropharyngeal inflammation (Grisel's syndrome) is most frequent 2
• Treatment for atlantoaxial subluxation varies by severity: soft cervical collar with rest and analgesics for minor acute cases, head halter traction for moderate cases, and halo traction or surgery for long-standing cases 5
• Cervical dystonia is rare but may occur in older adolescents 2