How should acute unilateral torticollis in a child be treated?

Treatment of Acute Torticollis in Children

Immediate Management: Multimodal Analgesia and Muscle Relaxation

For acute unilateral torticollis in a child, implement multimodal analgesia combining NSAIDs as first-line agents with heat therapy and gentle stretching exercises to control pain, reduce muscle spasm, and restore normal range of motion. 1, 2

First-Line Pharmacological Management

• Administer ibuprofen or naproxen as the primary analgesic to control pain and reduce inflammation in the affected sternocleidomastoid muscle 2
• Add acetaminophen for additional pain relief during the first 24-48 hours if NSAIDs alone are insufficient 1, 2
• Avoid benzodiazepines for muscle relaxation as they are conditionally recommended against in musculoskeletal pain conditions 1, 2
• Consider a short course of oral corticosteroids (3-5 days) only for severe cases with significant pain and muscle spasm to rapidly reduce inflammation 1, 2

Non-Pharmacological Interventions

• Apply heat to the affected neck area for 15-20 minutes, 3-4 times daily to relax tense muscles and improve blood circulation 1, 2
• Implement gentle stretching exercises to gradually restore normal range of motion, avoiding forceful manipulation 1
• Ensure proper positioning during rest and sleep with the head in neutral alignment to prevent worsening of symptoms 1, 2

Critical Red Flags Requiring Urgent Evaluation

Before attributing torticollis to simple muscle spasm, you must actively exclude life-threatening conditions:

• Progressive neurological symptoms including weakness, numbness, or tingling in the extremities suggest spinal cord compression and require immediate imaging 1, 2
• Fever with torticollis raises concern for retropharyngeal abscess, cervical adenitis, or Grisel's syndrome (atlantoaxial rotatory subluxation from pharyngeal inflammation) 3, 4
• Painless torticollis should raise suspicion for posterior fossa tumor or other central nervous system pathology 5, 4
• Torticollis with headache, vomiting, or altered mental status may indicate cerebellar tumor, brainstem lesion, or acute disseminated encephalomyelitis 5, 4
• Worsening pain despite appropriate medication within 48-72 hours warrants urgent re-evaluation 2

Diagnostic Considerations Before Treatment

• Rule out ocular causes such as eye muscle weakness (superior oblique palsy) or congenital cataract, which can present as compensatory head tilt 1, 2, 6
• Obtain cervical spine radiographs to exclude congenital vertebral anomalies, atlantoaxial rotatory displacement, or bony pathology 6, 7, 3
• Consider imaging (CT or MRI) if no improvement with initial management or if any neurological symptoms develop 1, 2, 3
• Distinguish inflammatory torticollis (from upper respiratory infection, sinusitis, otomastoiditis, or retropharyngeal abscess) from simple muscular torticollis through careful examination for fever, pharyngeal erythema, or cervical lymphadenopathy 3, 4

Home Care Instructions and Follow-Up

• Provide written discharge instructions as patients rarely remember verbal instructions alone 2
• Limit screen time and activities requiring prolonged neck positioning to avoid exacerbating muscle spasm 2
• Allow school attendance but restrict physical education until follow-up evaluation confirms resolution 2
• Schedule follow-up within 48-72 hours if symptoms do not improve with initial management 2

Common Pitfalls to Avoid

• Never perform spinal manipulation in infants or young children with torticollis without first ruling out congenital vertebral anomalies or craniospinal pathology, as a case report documented quadriplegia after manipulation in an infant 1
• Do not assume all torticollis is benign muscular tightness – missing nonmuscular causes (tumor, infection, atlantoaxial subluxation) can be life-threatening 7, 4
• Do not delay imaging in children with acquired torticollis and neurological symptoms as craniospinal tumors, cerebellar lesions, and spinal cord pathology commonly present this way 4
• Recognize that atlantoaxial rotatory displacement is the most common cause of acute torticollis in older children, often following trauma or upper respiratory infection (Grisel's syndrome) 6, 3