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Acute Cervical Torticollis Cheat Sheet by

Management, Presentation of ACT

Tortic­ollis

- Common neck posture of a patient with tortic­ollis, note the spasm/­act­ivation of the SCM
- Caused by involu­­ntary unilateral contra­­ction of the SCM and Traps other muscles are splenius, scapula muscles, scalenes and platysma
- More common in females aged 30-50 years
- Causes lateral flexion and contra­­la­teral rotation
- Antero­collis more rare, rotational more common

Types of Tortic­ollis

- Congen­ital: (caused by lesions in SCM (child­birth trauma), vertebral defomities e.g Hemive­rtebra, klippel feil)
- Acquired: post trauma (within days or 3-12 months­)/a­djacent inflam­matory process (Osteo­mye­lit­is,­lym­pha­den­itis, pharyg­itis, tonsil­itis, cervical abcesses, tumour, RA, Partial disloc­ation of C1 on C2
- Spasmodic: Cervical Dystonia - unknown origin
- Acute: Benign - affects younger and middle aged patients , sudden onset -self resolves days/weeks
- Dermat­ogenic: When the skin of the neck is injured it shortens (scars­/burns)
- Occular: Compen­sat­ional paralysis of the muscles that control inclin­ation and rotation of the head - oblique extrao­ccular muscles

Presen­tation

- Patient remembers doing something strenous or new the day before
- On observ­ation patient has painful fixed posture of lateral flexion and contra­lateral rotation of the head (can have flexion, extension, right/left tilt)
- Movement is painful and ROM is limited (lateral flexion and extension to the side of pain)
- Sleep is disturbed
- +ve Spurlings
- Palpation reveals unilateral hypert­oni­cit­y/spasm of the SCM, traps and LS
- Inters­ect­ional joint restricion
- Assess shoulder, scapular girdle
- Check for patient's drugs - Dopamine blockers, Ketamine, ammphe­tam­ines, cocaine, compazine, haldol and thorazine
- In patients with Down syndrome with tortic­ollis, consider atlant­o-axial instab­ility
- Assess for s/s of cervical adenopathy (lymph nodes), oropha­rynx, otoscopy, fundoscopy

DDx

- Essential Tremour
- Myasthenia Gravis
- MS
- Neurol­eptic agent toxicity
- Parkinsons
- Perito­nsillar Abscess
- Rehabi­lit­ation and cerebral palsy
- Retrop­har­yngeal Abscess
- Spinal Haematoma
- Tardive Dyskinesia
- Wilson disease

Imaging

Usually unnece­ssary unless:
- Trauma and "red flags"

Red Flags

- Fever (infec­tio­n/i­nfl­amm­atory - usualy septic otolar­yng­olo­gic­al/­ost­eoa­rticulr infection)
- Swollen Lymph nodes
- Signif­icant headache
- Difficulty breathing, swallowing or speaking
- Ataxia
- Weakness, numbness or parast­hesia in extrem­ities
- Change in bladde­r/bowel habits
- Strabismus
- Nystagmus
- Increased ICP (Vomiting, Double vision, Confusion, headache, papilo­edema)
- Reccurent vomiting

Management

- More serious causes should be ruled out
- Ice/heat
- Myofascial release of SCM, traps, LS and paraspinal muscles
- Stretching - Cx tracti­oning whilst resting your forearms on the patient's shoulders, forearms downward pressure, then ask patient to push against forearms with their shoulders against your resistance for 5-7 seconds while inhaling, ask patient to exhale and then stretch out and increase traction, process should be repeated 3 times
- Scapula reposi­tioning
- SMT if tolerable
- Avoidance of sleeping on the stomach or drafty conditions
- Cervical pillows recomm­ended
- NSAIDs and counte­rir­ritant creams, Benzod­iaz­epines, muscle relaxants, antich­oli­ner­gics, botox
- Surgery for some types
 

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