Abnormal head position
Reassure
- Head tilt is abnormal – you can only reassure once an underlying aetiology is found
- Cause will either be:
- Local congenital sternocleidomastoid mass
- Local infective cause e.g. lymphadenitis
- Visual problem
- Tumour at base of the neck
Action
Course of antibiotics if thought to be infective with review two weeks after onset
Physio referral if local
Review / Refer
- Head tilt or torticollis less than two weeks
- Normal visual assessment
- No corroborating findings of ENT or lymph node infection
- Any worrying features
- No/little improvement following postural advice
Action
Refer children with no resolution
Review children treated with antibiotics for reassessment and examination including full visual assessment
Scan
- Unresolved/persistent head tilt or torticollis with no identified cause
- Head tilt with one or more other symptoms suggestive of brain tumour
- Head tilt with associated high risk condition
- Head tilt with abnormal neurological or visual examination
Action
Scan
Diagnostic Pitfalls
- Attributing torticollis or head tilt to a local cause without corroborating features
Examination/assessment
- Determine duration of head tilt or torticollis
- Assess ENT
- Ask specifically about associated symptoms and risk factors:
- Personal or family history of a brain tumour
- Leukaemia
- Sarcoma and early onset breast or bowel cancer prior therapeutic CNS irritation
- Neurofibromatosis types 1 and 2
- Tuberous Sclerosis
- Li Fraumeni Syndrome
- Family history of colorectal polyposis
- Gorlins Syndrome
- Other familial genetic syndromes
- Neurological examination (include assessment of vision (including acuity), gait and coordination)
- Full visual assessment
- Plot growth for all children and pubertal status if applicable
- Plot head circumference in children under two
Worrying features
- Persistent head tilt with no resolution