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Emergency and Acute Medicine – Torticollis
Torticollis, meaning “twisted neck,” is a clinical symptom rather than a disease entity. It refers to a fixed or dynamic abnormal posture of the head and neck, often involving rotation or tilting. It is also known as cervical dystonia or wry neck and may arise from a wide range of local or central causes.
The etiology of torticollis is broad and can be categorized into local and central causes. The most common form is acute wry neck, which typically develops अचानक (often overnight) without clear provocation and resolves spontaneously within 1–2 weeks. Local structural causes include cervical spine pathology such as fractures, dislocations, subluxations, spondylosis, tumors, ligamentous laxity (especially in the atlantoaxial region), and scar tissue from prior injury. Inflammatory or infectious causes include myositis, lymphadenitis, tuberculosis, and infections of surrounding tissues such as retropharyngeal abscess, meningitis, tonsillitis, mastoiditis, or sinusitis. Neurologic and neuromuscular causes include myasthenia gravis and neuritis. Compensatory torticollis may occur with ocular muscle palsy or head tremor.
Central causes include idiopathic spasmodic torticollis, which is more common in women aged 31–60 years, as well as dystonic disorders such as torsion dystonia, tardive dystonia from neuroleptic medications, Wilson disease, and toxic causes such as Strychnine poisoning. Drug-induced dystonia, particularly from antipsychotics, is a common acute cause and typically occurs within 12–23 hours of medication exposure.
In pediatric patients, causes include congenital abnormalities such as muscular torticollis due to sternocleidomastoid hypertrophy, vertebral anomalies, or syndromic conditions. Other causes include infections (e.g., otitis media, retropharyngeal abscess), trauma, gastroesophageal reflux, and central nervous system pathology such as posterior fossa tumors.
Clinically, patients present with intermittent or sustained painful spasms of the neck muscles, particularly the sternocleidomastoid and trapezius. The head is typically rotated and tilted to one side, with movements ranging from smooth deviation to jerking motions. Pure flexion (anterocollis) or extension (retrocollis) is uncommon. Symptoms are often exacerbated by activity, stress, or upright posture and typically resolve during sleep.
History should focus on recent trauma, medication exposure (especially antipsychotics), and systemic symptoms such as fever. On examination, the abnormal head posture is evident, and neurologic evaluation is essential. The presence of fever suggests an infectious cause, while focal neurologic deficits raise concern for central nervous system or spinal cord pathology. In congenital cases, a firm, nontender mass in the sternocleidomastoid muscle may be present.
Evaluation is directed at excluding serious causes. Cervical spine imaging is indicated when trauma is suspected. CT or MRI may be required if there is concern for abscess, tumor, or neurologic pathology. Ultrasound is the preferred modality for congenital muscular torticollis. No specific laboratory tests are routinely helpful.
Management depends on the underlying cause. Prehospital care includes ensuring airway patency, supporting the head, and maintaining cervical spine precautions if trauma is suspected. In the emergency setting, immobilization is essential when fracture is a concern.
For drug-induced torticollis, treatment with diphenhydramine or benztropine is highly effective. For non-drug-related cases, conservative management includes rest, soft cervical collar, physical therapy, massage, local heat, and analgesics. Benzodiazepines may be used for muscle relaxation. Botulinum toxin is the first-line treatment for chronic or non–drug-induced torticollis, although it is typically administered in an outpatient setting.
Patients require admission if there is suspicion of cervical spine fracture, infection, toxic appearance, inability to maintain hydration, or diagnostic uncertainty. Most uncomplicated cases can be managed as outpatients with referral to specialists such as neurologists, orthopedists, or neurosurgeons.
Key clinical pearls include always excluding serious causes such as infection (e.g., retropharyngeal abscess or meningitis), trauma, and central nervous system pathology before attributing symptoms to benign torticollis. Drug-induced dystonia is common and rapidly reversible with appropriate treatment, and failure to recognize life-threatening causes can lead to significant morbidity.
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