Acquired Torticollis

“Twisted neck” — a non-specific sign with a wide differential. Most cases (especially in children) are benign muscular torticollis (wry neck) managed with simple analgesia, but exclude serious causes. (For the infant type, see congenital muscular torticollis under Paediatric MSK.) For neck pain following a car crash or similar deceleration mechanism, see Whiplash-Associated Disorder instead — a different entity with its own grading and management.

Causes

Muscle spasm (wry neck); trauma (fracture/dislocation, spinal haematoma); atlantoaxial rotatory subluxation; infection (retropharyngeal abscess, cervical/CNS/upper-lobe); inflammation (juvenile idiopathic arthritis); neoplasm (posterior fossa or bone tumours); dystonic reactions (e.g. metoclopramide, antipsychotics) and idiopathic spasmodic torticollis; ocular dysfunction; benign paroxysmal torticollis.

Assessment (red flags in bold)

• Time course: uncomplicated acute torticollis resolves in 7–10 days.
• Awkward-position history (flight, unusual sleep); any trauma.
• Infective: fever, drooling, sore throat, dysphagia → suspect retropharyngeal abscess.
• Neurological: headache, strabismus/diplopia, photophobia, ataxia.
• Drugs causing acute dystonia (metoclopramide).
• Examine: neck ROM/tenderness, full neurological, ENT (incl. nodes), ophthalmological and chest exams (deep pathology may have no external signs).

Investigations and management

• Cervical X-ray if cervical tenderness, severe/persistent pain (≥1 week), or atlantoaxial-instability risk (Down, Morquio, Larsen, Marfan syndromes). CT for neurological signs, severe unrelieved pain, bony anomaly, or suspected retropharyngeal abscess.
• Treatment: heat, massage and analgesia for most; diazepam for sternocleidomastoid spasm; cause-specific therapy — antibiotics + ENT referral for deep-space infection, benztropine for a dystonic drug reaction, Aspen collar/rest for atlantoaxial rotatory fixation, orthopaedic referral for injury/bony cause.