Torticollis
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Classification and main causes
| Type | Age and background | Mechanism | Features |
|---|---|---|---|
| Acute benign torticollis («waking torticollis») | Young adult + teenager - very frequent | Acute muscle contracture (SCM + trapezius + cervical paravertebrae) + often after poor night-time posture + cold + draught + sudden movement | Sudden onset on awakening + unilateral pain + limitation of rotation + spontaneous resolution in 3-10 days + symptomatic treatment |
| Congenital muscular torticollis (CMT) | Infant - present from birth or for the first few weeks | Fibrosis + shortening of the SCM (sternocleidomastoid) + often related to obstetrical trauma or prolonged intrauterine position | Palpable mass in the SCM (fibroma) + ipsilateral tilt + contralateral rotation + associated plagiocephaly + essential early physiotherapy |
| Cervical dystonia (spasmodic torticollis) | Adult 30-60 years - chronic movement disorder | Focal dystonia - involuntary + sustained + or intermittent cervical muscle contractions → postural head deviation | Rotation + involuntary head tilt + antagonistic gesture (touching the cheek = «sensory trick») + initial progression then stabilization + botulinum toxin = reference treatment |
| Post-traumatic torticollis | All ages - after cervical trauma | Cervical sprain + fracture + or subluxation (odontoid fracture + C1-C2) + muscle hematoma | Intense pain + stiffness + X-rays + emergency cervical CT if significant trauma + immobilization if fractured |
| Inflammatory/infectious torticollis | Child ++ - adult | Arthritis of C1-C2 (Grisel's syndrome - post-infectious atlantoaxial subluxation after angina + adenoidectomy) + retropharyngeal abscess + meningitis + cervical adenitis | Fever + dysphagia + trismus + urgent cervical CT + IV antibiotics + sometimes surgical drainage |
| Medicated torticollis (acute dystonia) | All ages - after dopaminergic medication | Acute iatrogenic dystonia due to D2 dopamine receptor blockade → metoclopramide + haloperidol + droperidol + phenothiazines → onset 24-48 h after intake | Torticollis ++ + trismus + ocular deviation (oculogyric crisis) + opisthotonos → emergency → biperiden 5 mg IM or IV + or diphenhydramine 25-50 mg IV |
| Secondary neurological torticollis | Child + adult - red flag | Posterior fossa tumor + syringomyelia + Chiari malformation + herniated cervical disc + brainstem stroke | Associated with neurological signs (headache + nystagmus + ataxia + diplopia + motor deficit) → urgent cerebral and cervical MRI |
Red flags - torticollis requiring urgent investigation
- Fever + torticollis in children : Grisel syndrome (post-infectious atlantoaxial subluxation) + retropharyngeal abscess + meningitis → urgent cervical CT scan + infectious workup
- Recent cervical trauma: fracture + cervical subluxation → X-rays + cervical CT → cervical immobilization until confirmation of absence of unstable fracture
- Associated neurological deficit : limb weakness + gait disorders + nystagmus + diplopia + dysphagia + ataxia → urgent brain and cervical MRI (tumor + syringomyelia + Chiari)
- Infant < 3 months with torticollis : MRI or ultrasound of the SCM to confirm TCM + and exclude a neurological or spinal cause
- NSAID-resistant torticollis after 10-14 days: systematic etiological investigation
- Acute drug-induced dystonia: torticollis + trismus + ocular deviation within 24-48 h after antiemetic or antipsychotic → biperiden IM or diphenhydramine IV as emergency treatment
Treatment by type
- Benign acute torticollis : NSAIDs (ibuprofen 400-600 mg × 3/d) + paracetamol + muscle relaxants (methocarbamol + cyclobenzaprine) + local heat + gentle physiotherapy + maintenance of usual activity (avoid strict immobilization) + resolution in 3-10 days + no cervical collar recommended (delays healing)
- Congenital muscular torticollis (infant) : early intensive physiotherapy (passive stretching of the SCM + contralateral strengthening) × from the first weeks → resolution in 90-95 % if started before 3 months + repositioning (avoid plagiocephaly) + surgery (tenotomy of the SCM) if failure at 12-18 months
- Cervical dystonia (spasmodic torticollis) : botulinum toxin type A (onabotulinumtoxinA - Botox® + or abobotulinumtoxinA - Dysport®) injected into dystonic cervical muscles → reduction of spasms + improvement of posture + efficacy 70-90 % + duration 3-4 months → repeated injections every 3-4 months + anticholinergics (trihexyphenidyl) if toxin insufficient + DBS if severe refractory cervical dystonia
- Acute drug-induced dystonia (emergency) : biperiden (Akineton®) 5 mg IM or IV → efficacy in 15-30 minutes + or diphenhydramine 25-50 mg IV + or benztropine + discontinuation of causal drug
- Grisel syndrome: IV antibiotics (amoxicillin-clavulanate + or cefazolin depending on cause) + NSAIDs + cervical immobilization + orthopedic reduction if subluxation + rarely surgery
Consult an emergency room immediately if torticollis is accompanied by fever in a child + recent cervical trauma + limb weakness + visual disturbances + difficulty swallowing + or if sudden torticollis + trismus and ocular deviation appear within 48 hours of taking anti-nausea or antipsychotic medication (acute dystonia medicamentosa - emergency biperiden IM). For benign acute torticollis without red flag, Clinique Omicron offers medical consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners diagnose and treat benign acute torticollis (NSAIDs + muscle relaxants + physiotherapy), identify red flags requiring urgent investigation (CT scan + cervical MRI), detect congenital muscular torticollis in infants and refer for early physiotherapy, recognize acute drug-induced dystonia and administer anticholinergic treatment, and refer to neurology for chronic cervical dystonia (botulinum toxin injections). Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for information purposes only and does not replace the advice of a physician or neurologist. Any febrile torticollis in children or associated with neurological signs requires urgent investigation to exclude atlantoaxial subluxation, retropharyngeal abscess or posterior fossa tumor. Cervical collars are not recommended for benign acute torticollis, as they delay healing.
Omicron Clinic
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