Ok ladies and gents, here is the final CotM for this academic year, why not marinate on a peds case.
You are working in the peds emergency department when an ortho resident brings in a patient from his clinic for you to evaluate for torticollis.
You are presented with a 7 y/o boy with a PMH of scoliosis and asthma. He was brought for his regular scoliosis appointment, but his mother shares that for two weeks the patient cannot turn his head completely due to pain and stiffness. Last week, she had to pick him up early from school because he was complaining of pain in his L arm that was radiating from his neck, however he has not had pain since. The patient says he had a sore throat and cough before the stiffness started; his mother says he is always coughing due to asthma. Those symptoms have now resolved. His scoliosis is mild, involving his thoracic spine. Has never had neck problems before.
Denies trauma, falls, twisting, head manipulation, fevers, chills, N/V/D, sick contacts, recent travel, headache, vision changes, numbness, tingling, weakness.
Meds Albuterol prn
VS HR 95, BP 115/70, afebrile, RR 14, Sat 100% on RA
PE normal aside from
Head is tilted to the R
Decreased ROM of neck in both directions
L cervical muscle spasm and tenderness
L anterior and posterior cervical LAD
Oropharynx clear with no evidence of abscess or exduates
Please discuss this case by answering these questions:
What is your RANKED differential in this pediatric patient with torticollis?
What will your workup include?
What is your management for your chosen diagnosis?
Good luck, winner gets the usual fame and fortune and a free beverage on me.
James Hassel
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2 Comments
nisasi · June 9, 2015 at 5:57 pm
This is acquired torticollis due to acute infection including viral or streptococcal pharyngitis and viral URI. Also consider muscle inflammation/injury in setting of cough or sleep position. Also consider retropharyngeal abscess, parapharyngeal abscess, although patient is without signs of these.
Less likely causes include cervical adenitis, cervical spine injury, spinal epidural hematoma, CNS tumur, Lemierre syndrome, osteomyelitis, diskitis, tuberculosis (Pott disease), and right upper lobe pneumonia.
Workup includes ensuring normal airway and rapid assessment for any serious causes for acquired torticollis such as trauma and serious infectious etiologies, including RPA and Lemierre’s syndrome. In this patient with persistent torticollis of what appears to be less serious infectious cause, C-spine X-rays would be indicated although I anticipate it to be unremarkable.
Given that the patient likely had a URI/pharyngitis episode precedeing torticollis (given LAD) that has resolved, mgmt would be supportive with NSAIDs and cervical collar as needed for comfort. A short course of Valium may be used if NSAIDs do not work. Follow up should be ensured for the patient especially if these measures do not work as additional etiologies would need to be considered and further imaging done.
monamuch12 · June 11, 2015 at 12:04 am
Differential: SCM myositis > RPA > Non-traumatic atlantoaxial sublaxation> Cat scratch disease > PTA > Cervical radiculopathy
Work up: Lateral Neck Xray, CBC w/ diff
Management: LIkely SCM myositis (most common in kids) so supportive therapy (NSAIDs)