The Differential Diagnosis of Torticollis in Children

Torticollis is a term that describes asymmetrical posturing of the head and neck. The majority of children who present with torticollis during the first year of life have congenital muscular torticollis (CMT) secondary to unilateral fibrosis of the sternocleido-mastoid muscle. Observation alone leads to residual deformity in up to 20% of these children, but aggressive treatment of CMT improves outcome. One in five children presenting with torticollis have a non-muscular etiology with either soft tissue involvement or bony involvement. Other diagnoses associated with torticollis include benign paroxysmal torticollis, congenital absence of one or more cervical muscles, Klippel-Feil syndrome, hemivertebrae, or other congenital anomalies of the cervical spine. Acquired torticollis may be secondary to trauma, or children can develop torticollis secondary to inflammatory conditions such as pharyngitis. Torticollis is also seen in response to certain ocular lesions as well as in children with symptomatic hiatal hernias. The most dangerous cause of non-muscular acquired torticollis is related to neurologic syndromes, such as syringomyelia, dystonic or post-encephalitic syndromes, herniated cervical discs, and, especially, posterior fossa pathology. In a large series of children with non-muscular torticollis, 10% resulted from neurologic problems, half of which involved tumors. When torticollis is encountered, a search for a diagnosis should begin. After a diagnosis is made, treatment can begin.