One sunny afternoon in one of our busy and well respected emergency departments an 8 year old girl presents with a "wry neck". She had woken up in that morning with an extremely painful neck, her head tilted over to the right, and unable to move it in any direction.
On further questioning she had had a minor fall in the playground the day beforehand. She had a viral illness about a week ago and had a sore throat.
On examination she appeared alert and well. Her voice was normal, there was no respiratory distress and no stridor. Temp 37.8, PR 100, and normal hydration. Minor tender cervical lymphadenopathy.
Her head was held in a fixed torticollis with head tilted to the right and chin to the left. It was very painful for her to move her neck in any direction including extension.
A lateral neck xray was performed:
On further questioning she had had a minor fall in the playground the day beforehand. She had a viral illness about a week ago and had a sore throat.
On examination she appeared alert and well. Her voice was normal, there was no respiratory distress and no stridor. Temp 37.8, PR 100, and normal hydration. Minor tender cervical lymphadenopathy.
Her head was held in a fixed torticollis with head tilted to the right and chin to the left. It was very painful for her to move her neck in any direction including extension.
A lateral neck xray was performed:
Interpretation
The lateral soft tissue neck film shows significant soft tissue swelling anterior to the C2-C5 cervical vertebrae consistent with a retropharyngeal abscess.
Normal soft tissue distances should be 7mm at C2 and 2cm at C7. Any increase in soft tissue thickness may represent infection but is also an important indicator of underlying cervical spine injury in the setting of trauma. Clinical history and examination are, as always, vital.
Causes of torticollis in children:
While the most common cause of acquired torticollis in children (approx 60%) is injury or inflammation involving the sternocleidomastoid or trapezius muscle, it's really important to consider less common but potentially life threatening conditions during your initial assessment:
Retropharyngeal abscess (confirmed on MRI in this case).
Usually a disease of 2-4 year olds - there is an exception to every rule- early in the disease process, the findings may be indistinguishable from those of uncomplicated pharyngitis.
With disease progression, symptoms related to inflammation and obstruction of the upper aerodigestive tract develop. Children with retropharyngeal abscess generally appear ill with moderate fever.
Additional symptoms may include:
Other life threatening causes of torticollis include:
Normal soft tissue distances should be 7mm at C2 and 2cm at C7. Any increase in soft tissue thickness may represent infection but is also an important indicator of underlying cervical spine injury in the setting of trauma. Clinical history and examination are, as always, vital.
Causes of torticollis in children:
While the most common cause of acquired torticollis in children (approx 60%) is injury or inflammation involving the sternocleidomastoid or trapezius muscle, it's really important to consider less common but potentially life threatening conditions during your initial assessment:
Retropharyngeal abscess (confirmed on MRI in this case).
Usually a disease of 2-4 year olds - there is an exception to every rule- early in the disease process, the findings may be indistinguishable from those of uncomplicated pharyngitis.
With disease progression, symptoms related to inflammation and obstruction of the upper aerodigestive tract develop. Children with retropharyngeal abscess generally appear ill with moderate fever.
Additional symptoms may include:
- Difficulty swallowing (dysphagia), pain with swallowing (odynophagia), and/or drooling with decreased oral intake
- Unwillingness to move the neck secondary to pain (torticollis), particularly unwillingness to extend the neck
- Change in vocal quality (muffled, or with a "hot potato" quality [dysphonia]), gurgling sound, or stertor
- Respiratory distress (stridor, tachypnea, or both); stridor develops as disease progresses
- Neck swelling, mass, or lymphadenopathy
- Trismus (in approximately 20 percen
- Chest pain (if there is mediastinal extension)
Other life threatening causes of torticollis include:
- Suppurative jugular thrombophlebitis (Lemierre syndrome) (typically high fevers, rigors and respiratory distress),
- cervical spine injury (high energy kinetic mechanisms such as MVAs and falls),
- spinal epidural haematoma (particularly in haemophiliacs) and
- CNS tumours (consider if headache, vomiting, visual disturbances, papilloedema or CN deficits)
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