What is the recommended treatment approach for a child diagnosed with torticollis (wry neck)?

Treatment Approach for Pediatric Torticollis

The initial management of torticollis in children must first distinguish between benign muscular torticollis and potentially life-threatening nonmuscular causes through systematic evaluation, followed by multimodal conservative therapy for muscular cases. 1, 2, 3

Critical First Step: Differentiate Muscular from Nonmuscular Causes

Immediately evaluate for red flags requiring urgent imaging and specialist referral: 2, 3

• Neurological symptoms (headaches, vomiting, altered mental status, weakness, numbness, or tingling in extremities) 2, 4
• Multiple cranial nerve palsies suggesting brainstem or cavernous sinus pathology 2
• Diplopia or extraocular movement limitations 2
• Progressive symptoms despite initial treatment 4
• Ptosis or other cranial nerve deficits 2

If any red flags present: Obtain urgent MRI of brain and brainstem before initiating conservative treatment 2. Missing nonmuscular torticollis can be life-threatening, while congenital muscular torticollis is benign 3.

Age-Specific Diagnostic Considerations

For infants (<3 months): 2, 5

• Benign paroxysmal torticollis (BPT): Recurrent episodes of painless head postures alternating from side to side 1, 2
• Sandifer syndrome: Head tilt associated with gastroesophageal reflux, particularly after eating 2, 5
• Ocular torticollis: Rule out eye muscle weakness as a cause 1, 4

For older children: 5

• Consider atlantoaxial rotatory displacement from trauma or oropharyngeal inflammation (Grisel's syndrome) 5
• Evaluate for posterior fossa tumors if intermittent torticollis with headaches or vomiting 5

Conservative Management Protocol for Muscular Torticollis

Immediate Pharmacological Management

First-line pain control: 4

• NSAIDs (ibuprofen or naproxen) as primary agents for pain and inflammation reduction 4
• Acetaminophen for additional pain relief during first 24-48 hours 1, 4
• Avoid benzodiazepines - not recommended for musculoskeletal pain in children 1, 4
• Short course of oral corticosteroids may be considered for severe pain cases to rapidly reduce inflammation 1, 4

Physical Therapy Interventions

Start physical therapy immediately, especially within the first year of life for optimal outcomes: 3, 6

• Manual cervical stretching exercises - most effective when instituted early 3, 5
• Gentle manual therapy including mobilization and trigger point therapy 1
• Home exercise programs focusing on stretching and strengthening neck muscles 1
• Supervised postural exercises with or without manual trigger point therapy 1

Adjunctive Home Care Measures

Heat therapy: Apply to affected neck area for 15-20 minutes, 3-4 times daily to relax muscles and improve circulation 1, 4

Positioning: Ensure proper positioning during rest and sleep to prevent symptom worsening 1, 4

Activity modifications: 4

• May attend school but avoid physical education until follow-up
• Limit screen time and activities requiring prolonged neck positioning

Treatment Escalation for Refractory Cases

If inadequate response to conservative therapy after appropriate trial: 7, 6

• Botulinum toxin type A injection into affected sternocleidomastoid muscle has shown effectiveness in recalcitrant cases, potentially avoiding surgical release 7
• Surgical release (sternocleidomastoid muscle lengthening) is reserved for cases presenting after age 1 year or failing conservative measures, though it may improve range of motion but not necessarily plagiocephaly or facial asymmetry 3

Imaging Considerations

Cervical spine radiographs: Obtain to rule out congenital anomalies of occipital condyles and upper cervical spine before considering surgical intervention 3, 5

MRI of brain and neck: No longer considered cost-effective or necessary in congenital muscular torticollis unless red flags present 3

Critical Pitfalls to Avoid

• Never assume muscular cause without systematic evaluation - missing nonmuscular torticollis can be life-threatening 3
• Do not delay imaging if neurological symptoms present 2, 4
• Avoid performing sternocleidomastoid release without first ruling out congenital cervical spine anomalies 3, 5
• Provide written discharge instructions as patients rarely remember verbal instructions alone 4