An Undesirable Sideways Glance
An Undesirable Sideways Glance
Sam is a 3-year-old who came to the office 2 weeks ago with the complaint of a stiff neck. His mother reported that Sam had played for several hours at a local playground the day before and on the morning of the appointment he had awakened with a complaint of difficulty turning his head. No specific injury was witnessed, and there were no signs of illness. His examination then was essentially normal except for mild resistance to passive range of motion of his neck. He was sent home with a diagnosis of torticollis due to muscle spasm and treated with warm soaks to his neck and ibuprofen.
Sam returns today because the complaints of having a stiff neck have continued. His mother has noticed he seems to be turning his body, not his neck, when looking to the side. She also comments that Sam's grandmother, who cares for him when his mother works, is concerned that Sam has had several episodes of choking on his food. Sam's mother has not witnessed this choking and has assumed it is because Sam is distracted by the dog while he is eating at his grandmother's house.
As you are talking with Sam's mother, you note that Sam is sitting in a hunched position with a shortened appearance to his neck. As you stand to his left side, he turns his torso toward you to talk. Further examination shows resistance to flexion and extension of his neck. No cervical adenopathy or other abnormal findings are noted upon an ear, nose, and throat examination. The remainder of his examination is within normal limits.
A review of Sam's medical record shows that Sam has been a patient at your practice since infancy and that several providers have seen him for frequent ear and sinus infections. At his 2-year-old physical, his mother mentioned to the provider that Sam had intermittently complained of his back hurting. His examination was normal, and his mother was directed to call if his complaints of back pain continued, at which time an x-ray would be obtained. No further mention of any complaints of back pain were included in his chart. At age 2 years and 10 months, Sam was seen for a sinus infection, 3+ enlarged tonsils, and mild torticollis. He was treated with an antibiotic and monitored closely by telephone. All symptoms reportedly resolved. Two weeks later Sam returned with complaints of recurrent nasal congestion and swollen tonsils, and again his head was tilted slightly to the right. He was sent for lateral neck and sinus films, which showed moderate hypertrophy of his adenoids and hypertrophy of his lingular tonsils without mention of any other abnormality. He was referred to an ear, nose, and throat specialist, who determined that observation only was adequate because summer was coming and Sam was getting older. His family history as documented is noncontributory.
Introduction
Sam is a 3-year-old who came to the office 2 weeks ago with the complaint of a stiff neck. His mother reported that Sam had played for several hours at a local playground the day before and on the morning of the appointment he had awakened with a complaint of difficulty turning his head. No specific injury was witnessed, and there were no signs of illness. His examination then was essentially normal except for mild resistance to passive range of motion of his neck. He was sent home with a diagnosis of torticollis due to muscle spasm and treated with warm soaks to his neck and ibuprofen.
Sam returns today because the complaints of having a stiff neck have continued. His mother has noticed he seems to be turning his body, not his neck, when looking to the side. She also comments that Sam's grandmother, who cares for him when his mother works, is concerned that Sam has had several episodes of choking on his food. Sam's mother has not witnessed this choking and has assumed it is because Sam is distracted by the dog while he is eating at his grandmother's house.
As you are talking with Sam's mother, you note that Sam is sitting in a hunched position with a shortened appearance to his neck. As you stand to his left side, he turns his torso toward you to talk. Further examination shows resistance to flexion and extension of his neck. No cervical adenopathy or other abnormal findings are noted upon an ear, nose, and throat examination. The remainder of his examination is within normal limits.
A review of Sam's medical record shows that Sam has been a patient at your practice since infancy and that several providers have seen him for frequent ear and sinus infections. At his 2-year-old physical, his mother mentioned to the provider that Sam had intermittently complained of his back hurting. His examination was normal, and his mother was directed to call if his complaints of back pain continued, at which time an x-ray would be obtained. No further mention of any complaints of back pain were included in his chart. At age 2 years and 10 months, Sam was seen for a sinus infection, 3+ enlarged tonsils, and mild torticollis. He was treated with an antibiotic and monitored closely by telephone. All symptoms reportedly resolved. Two weeks later Sam returned with complaints of recurrent nasal congestion and swollen tonsils, and again his head was tilted slightly to the right. He was sent for lateral neck and sinus films, which showed moderate hypertrophy of his adenoids and hypertrophy of his lingular tonsils without mention of any other abnormality. He was referred to an ear, nose, and throat specialist, who determined that observation only was adequate because summer was coming and Sam was getting older. His family history as documented is noncontributory.