The occipital encephalocele of the patient is seen ( a ). Sagittal T1 ( b ) and sagittal T2 ( c ) MR images show cerebellar encephalocele ( arrows ). Axial T2-weighted image ( d ) shows split cord at C1 – C2 level 

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Context 1

... torticollis, spasmodic torticollis, Sandifer syndrome, drug-induced torticollis, and conversion disorder [4, 6]. The purpose of this study is to contribute for a better under- standing of the spectrum of underlying diseases in torticollis. We would like to share our experience about what we learned from the children presented with torticollis within the last 2 years. Erciyes University Children s Hospital is a tertiary hospital in the city of Kayseri, in Central Anatolia, Turkey. This hospital is the sole pediatric referral center, for the surrounding cities in the Cappadocia region. We aimed to investigate the spectrum of underlying disease and to evaluate the clinical features of the children presented with torticollis in the last 2 years. Between May 2012 and November 2014, 20 patients (13 girls and 7 boys with the mean age of 8 years, ranging 2 months 12 years) followed in Erciyes University Children ’ s Hospital, were retrospective- ly who had such complaints as twisted neck, neck pain, weakness of extremity, esotropia, and gait disorder were enrolled in this study. Those cases with congenital muscular torticollis and/or with a history of medication intake were excluded from the study. Ethical permission for a review of all records was granted by the Ethics Committee of Erciyes University. In order to reveal etiology, cranial and/or spinal magnetic resonance imaging (MRI), MR angiography, MR spectrosco- py, CT imaging, sternocleidomastoid (SCM) ultrasound, and pH-meter studies were performed. Eight of the patients have craniospinal pathologies (cerebellar tumors in three, exophytic brain stem glioma, eosinophilic granuloma of C2 vertebra, neuroenteric cyst of the spinal cord, Chiari type 3 malformation, arachnoid cysts causing brainstem compression, and cerebellar empyema), followed by osseous origin in five children (congenital vertebral anomalies (hemivertebrae, blocked vertebra and segmentation anomalies)), two muscular torticollis (soft tissue inflammation due to subclavian artery catheterization, myositis ossificans with sternocleidomastoid muscle atrophy), and ocular (congenital cataract and microphthalmia), Sandifer syndrome, paroxysmal torticollis, retropharyngeal abscess each in one patients were detected (Table 1). Ten patients underwent surgery; two patients received medical therapy for reflux and benign paroxysmal torticollis; and one patient with torticollis due to muscle spasm and soft tissue inflammation was treated with physiotherapy. Two patients ’ parents refused the treatment. The rest of the patients were regularly observed without any intervention. We would like to present some of the interesting patients in details. Patient#2 A 31-month-old girl was admitted to us with complaints of left-side torticollis, gait disturbance, and left arm pain. On her neurological examination, left ptosis, size differences, and asymmetry between orbits were observed. On the MRI, cervical and thoracic intradural extramedullary mass, thinning of cervical spinal cord, and paravertebral cystic lesion were detected (Fig. 1). She underwent surgery, and gross totally resection was performed via posterior spinal surgery. The histopathological examination was reported as neuroenteric cyst. Patient#5 A 6-month-old girl with complaint of twisted neck was admitted to pediatric neurology outpatient clinic. She was born with caesarean section. There was no history of trauma. SCM muscle ultrasonography was normal. Although she had been treated with physical therapy and home stretching exer- cises, head tilt increased. On physical examination, torticollis, microcephaly, and microphthalmia were detected. Craniocervical MRI was normal. The serological tests performed for congenital infections were normal. After ophthalmologic consultation, she was diagnosed as cataract. She underwent a surgery. In the 6-month follow-up after surgery, the torticollis was resolved. Patient#9 A 7-month-old boy with twisted neck complaints was referred to pediatric neurology department; from his medical history, it was learned that he was evaluated for torticollis at another. The ultrasonography of SCM muscle, ophthalmologic examination, and cranial MRI were normal. There was no history of trauma or illness. On physical examination, scoliosis was detected which was undiagnosed because of inappropriate examination. Patient ’ s MRI confirmed scoliosis (Fig. 2). The patient was referred to the orthopedic clinic. Patient#10 A 12-year-old girl with complaints of torticollis and a mass in the occipital region was referred to the outpatient clinic of pediatric neurology department. Torticollis was not noticed until the age of 3 by her parents. On her physical examination, as well as torticollis, an about 30-mm-length bone defect and encephalocel sac in the occipital were observed (Fig. 3). MRI revealed an encephalocel containing meningeal structures and a posterior part of the vermis, a split cord abnormality in the upper cervical level (Fig. 3). The patient was diagnosed as Chiari type 3 and occipital encephalocel. Surgical treatment was recommended. But, the patient ’ s parents refused the surgical treatment. Patient#11 A 12-month-old girl with strabismus was admitted to pediatric neurology polyclinics. She was followed up for 3 months due to prematurity and germinal matrix hemorrhage. She had a history of six times shunt operations. On the physical examination, torticollis was detected on the left side. She had esotropia in the left eye due to nervous abducens paralysis. Deep tendon reflexes were found to have increased. MRI revealed an arachnoid cyst causing midline shift, compression of brainstem, and dilation of fourth ventricle (Fig. 4). Surgery was recommended for the arachnoid cyst, but the family refused the operation. Patient#12 An 11-month-old girl with the complaints of in- termittent torticollis and lethargy was admitted to pediatric neurology department. There was a history of a similar epi- sode at the age of 6 and 8 months ago, and the tilt was not always on the same side. The duration of the attacks was about 1 – 2 days and ceased spontaneously. Twisted neck, lethargy, and pallor were detected on physical examination during the attack. When any effort was made to straighten the head, it was observed that she had cried and resisted. There was no history for trauma or illness. Mental, motor, and physical de- velopments were normal. Her mother had recurrent headache attacks, which were accompanied by nausea and vomiting in the family history. Cranial, cervical MRI, ophthalmological evaluation, neck USG and pH monitoring, and radiological imaging were normal and so were ophthalmologic and audi- ological examinations. She was diagnosed as paroxysmal torticollis because all the tests to determine the etiology were normal. She was followed up clinically. She still receives an- tiemetic and analgesic treatment during attacks. Patient#13 A 55-month-old girl with a complaint of twisted neck and difficulty in coordinating the walking was admitted to emergency department. There was no history of trauma or illness. Torticollis, lethargy, and difficulty in coordinating movements were detected on the physical examination. Cranial MRI revealed a 51×46×49 mm mass on cerebellar vermis (Fig. 5). She underwent a surgery, and neuronavigation- assisted gross total tumor resection was performed. The histopathological examination was reported to be pilocytic astrocytoma. After the surgery, the torticollis improved completely. Patient#14 A 52-month-old boy with complaints of neck pain that started 2 weeks ago was admitted to the pediatric neurology department. Except for the torticollis, the neurologic examination was normal. There was no history of trauma or systemic illness. Craniocervical MRI revealed a collapse of the C2 corpus, T1W isointense, and T2W hyperintense mass on C2 (Fig. 6). He underwent a surgery and gross total mass resection, autograft, C1-C3 screw fixation were performed. The histopathological examination revealed the diagnosis of eosinophilic granuloma. After the surgery, torticollis was recovered completely. Patient#20 A 12-year-old girl with complaints of torticollis, headache, and vomiting which started 3 days ago was admitted to the emergency department. She had a 2-year history of chronic otitis media. On her medical examination, confusion, torticollis, and right perforated otitis media were observed. MRI revealed subdural empyema on the right cerebellum (Fig. 7). She underwent urgent empyema drainage, and after the surgery, antibiotic treatment was started. She recovered without any neurological sequel. The term torticollis or head tilt may be the initial symptom of a number of illnesses [5]. Differential diagnosis of the cause of a patient ’ s torticollis is critical for the physicians both to choose the correct treatment and not to give rise to a delayed or inappropriate treatment. Torticollis can originate from a variety of primary etiologies such as muscular, ocular, osseous, and neurological abnormalities [3, 4]. The initial medical evaluation of any patient with torticollis should include a thorough medical history and physical examination to rule out underlying hazardous diagnoses. The physical examination for children presenting with acquired torticollis must be focused on vital signs, head, eyes, neck, throat, lungs, and the neurological system [6]. Furthermore, neurological assessment, appropriate radiological examinations, adequate laboratory investigations, and ophthalmological consultation should be performed [7]. In children acquired torticollis due to cervical bony abnormalities, trauma, nasopharyngeal infections, and tumors of the central nervous system is more prevalent [8]. The underlying central nervous system (CNS) pathologies can be originated from three main groups: brain, spinal cord, and spinal nerve root/peripheral nerve. Delay in the diagnosis of these groups lead to progressive ...

Context 2

... system torticollis (brain, spinal cord, spinal nerve root/peripheral nerve), and soft tissue torticollis. The causes of paroxysmal torticollis are benign paroxysmal torticollis, spasmodic torticollis, Sandifer syndrome, drug-induced torticollis, and conversion disorder [4, 6]. The purpose of this study is to contribute for a better under- standing of the spectrum of underlying diseases in torticollis. We would like to share our experience about what we learned from the children presented with torticollis within the last 2 years. Erciyes University Children s Hospital is a tertiary hospital in the city of Kayseri, in Central Anatolia, Turkey. This hospital is the sole pediatric referral center, for the surrounding cities in the Cappadocia region. We aimed to investigate the spectrum of underlying disease and to evaluate the clinical features of the children presented with torticollis in the last 2 years. Between May 2012 and November 2014, 20 patients (13 girls and 7 boys with the mean age of 8 years, ranging 2 months 12 years) followed in Erciyes University Children ’ s Hospital, were retrospective- ly who had such complaints as twisted neck, neck pain, weakness of extremity, esotropia, and gait disorder were enrolled in this study. Those cases with congenital muscular torticollis and/or with a history of medication intake were excluded from the study. Ethical permission for a review of all records was granted by the Ethics Committee of Erciyes University. In order to reveal etiology, cranial and/or spinal magnetic resonance imaging (MRI), MR angiography, MR spectrosco- py, CT imaging, sternocleidomastoid (SCM) ultrasound, and pH-meter studies were performed. Eight of the patients have craniospinal pathologies (cerebellar tumors in three, exophytic brain stem glioma, eosinophilic granuloma of C2 vertebra, neuroenteric cyst of the spinal cord, Chiari type 3 malformation, arachnoid cysts causing brainstem compression, and cerebellar empyema), followed by osseous origin in five children (congenital vertebral anomalies (hemivertebrae, blocked vertebra and segmentation anomalies)), two muscular torticollis (soft tissue inflammation due to subclavian artery catheterization, myositis ossificans with sternocleidomastoid muscle atrophy), and ocular (congenital cataract and microphthalmia), Sandifer syndrome, paroxysmal torticollis, retropharyngeal abscess each in one patients were detected (Table 1). Ten patients underwent surgery; two patients received medical therapy for reflux and benign paroxysmal torticollis; and one patient with torticollis due to muscle spasm and soft tissue inflammation was treated with physiotherapy. Two patients ’ parents refused the treatment. The rest of the patients were regularly observed without any intervention. We would like to present some of the interesting patients in details. Patient#2 A 31-month-old girl was admitted to us with complaints of left-side torticollis, gait disturbance, and left arm pain. On her neurological examination, left ptosis, size differences, and asymmetry between orbits were observed. On the MRI, cervical and thoracic intradural extramedullary mass, thinning of cervical spinal cord, and paravertebral cystic lesion were detected (Fig. 1). She underwent surgery, and gross totally resection was performed via posterior spinal surgery. The histopathological examination was reported as neuroenteric cyst. Patient#5 A 6-month-old girl with complaint of twisted neck was admitted to pediatric neurology outpatient clinic. She was born with caesarean section. There was no history of trauma. SCM muscle ultrasonography was normal. Although she had been treated with physical therapy and home stretching exer- cises, head tilt increased. On physical examination, torticollis, microcephaly, and microphthalmia were detected. Craniocervical MRI was normal. The serological tests performed for congenital infections were normal. After ophthalmologic consultation, she was diagnosed as cataract. She underwent a surgery. In the 6-month follow-up after surgery, the torticollis was resolved. Patient#9 A 7-month-old boy with twisted neck complaints was referred to pediatric neurology department; from his medical history, it was learned that he was evaluated for torticollis at another. The ultrasonography of SCM muscle, ophthalmologic examination, and cranial MRI were normal. There was no history of trauma or illness. On physical examination, scoliosis was detected which was undiagnosed because of inappropriate examination. Patient ’ s MRI confirmed scoliosis (Fig. 2). The patient was referred to the orthopedic clinic. Patient#10 A 12-year-old girl with complaints of torticollis and a mass in the occipital region was referred to the outpatient clinic of pediatric neurology department. Torticollis was not noticed until the age of 3 by her parents. On her physical examination, as well as torticollis, an about 30-mm-length bone defect and encephalocel sac in the occipital were observed (Fig. 3). MRI revealed an encephalocel containing meningeal structures and a posterior part of the vermis, a split cord abnormality in the upper cervical level (Fig. 3). The patient was diagnosed as Chiari type 3 and occipital encephalocel. Surgical treatment was recommended. But, the patient ’ s parents refused the surgical treatment. Patient#11 A 12-month-old girl with strabismus was admitted to pediatric neurology polyclinics. She was followed up for 3 months due to prematurity and germinal matrix hemorrhage. She had a history of six times shunt operations. On the physical examination, torticollis was detected on the left side. She had esotropia in the left eye due to nervous abducens paralysis. Deep tendon reflexes were found to have increased. MRI revealed an arachnoid cyst causing midline shift, compression of brainstem, and dilation of fourth ventricle (Fig. 4). Surgery was recommended for the arachnoid cyst, but the family refused the operation. Patient#12 An 11-month-old girl with the complaints of in- termittent torticollis and lethargy was admitted to pediatric neurology department. There was a history of a similar epi- sode at the age of 6 and 8 months ago, and the tilt was not always on the same side. The duration of the attacks was about 1 – 2 days and ceased spontaneously. Twisted neck, lethargy, and pallor were detected on physical examination during the attack. When any effort was made to straighten the head, it was observed that she had cried and resisted. There was no history for trauma or illness. Mental, motor, and physical de- velopments were normal. Her mother had recurrent headache attacks, which were accompanied by nausea and vomiting in the family history. Cranial, cervical MRI, ophthalmological evaluation, neck USG and pH monitoring, and radiological imaging were normal and so were ophthalmologic and audi- ological examinations. She was diagnosed as paroxysmal torticollis because all the tests to determine the etiology were normal. She was followed up clinically. She still receives an- tiemetic and analgesic treatment during attacks. Patient#13 A 55-month-old girl with a complaint of twisted neck and difficulty in coordinating the walking was admitted to emergency department. There was no history of trauma or illness. Torticollis, lethargy, and difficulty in coordinating movements were detected on the physical examination. Cranial MRI revealed a 51×46×49 mm mass on cerebellar vermis (Fig. 5). She underwent a surgery, and neuronavigation- assisted gross total tumor resection was performed. The histopathological examination was reported to be pilocytic astrocytoma. After the surgery, the torticollis improved completely. Patient#14 A 52-month-old boy with complaints of neck pain that started 2 weeks ago was admitted to the pediatric neurology department. Except for the torticollis, the neurologic examination was normal. There was no history of trauma or systemic illness. Craniocervical MRI revealed a collapse of the C2 corpus, T1W isointense, and T2W hyperintense mass on C2 (Fig. 6). He underwent a surgery and gross total mass resection, autograft, C1-C3 screw fixation were performed. The histopathological examination revealed the diagnosis of eosinophilic granuloma. After the surgery, torticollis was recovered completely. Patient#20 A 12-year-old girl with complaints of torticollis, headache, and vomiting which started 3 days ago was admitted to the emergency department. She had a 2-year history of chronic otitis media. On her medical examination, confusion, torticollis, and right perforated otitis media were observed. MRI revealed subdural empyema on the right cerebellum (Fig. 7). She underwent urgent empyema drainage, and after the surgery, antibiotic treatment was started. She recovered without any neurological sequel. The term torticollis or head tilt may be the initial symptom of a number of illnesses [5]. Differential diagnosis of the cause of a patient ’ s torticollis is critical for the physicians both to choose the correct treatment and not to give rise to a delayed or inappropriate treatment. Torticollis can originate from a variety of primary etiologies such as muscular, ocular, osseous, and neurological abnormalities [3, 4]. The initial medical evaluation of any patient with torticollis should include a thorough medical history and physical examination to rule out underlying hazardous diagnoses. The physical examination for children presenting with acquired torticollis must be focused on vital signs, head, eyes, neck, throat, lungs, and the neurological system [6]. Furthermore, neurological assessment, appropriate radiological examinations, adequate laboratory investigations, and ophthalmological consultation should be performed [7]. In children acquired torticollis due to cervical bony abnormalities, trauma, nasopharyngeal infections, and tumors of the central nervous system is more prevalent [8]. The underlying central nervous system (CNS) pathologies can be ...