Hot Seat #241: Stiff Odds
Posted on: January 17, 2025, by : Brandon Ho
Case by Kammeron Brissett MD, CNH PEM Fellow
12 month old male presents with 3 days of left-sided neck stiffness and increased fussiness. Neck stiffness was first noticed after waking up from a nap 3 days ago. Mom states he appears to be reluctant to turn his neck to the left. He continues to maintain oral intake, as well as bowel and bladder habits. He has remained alert, and playful with his usual physical activity. Denies trauma. He has been afebrile, however recently completed a course of amoxicillin for bilateral otitis media. Since symptom onset has presented to an OSH ED and his PCP for his neck stiffness. No labs and images were obtained at these visits.
PMH: full term, R hydronephrosis, café au lait spots
PSH: circumcision
Medications: none
Allergies: NKDA
T : 36.9 C HR 139 RR 28 SPO2 100%
General: Alert. appropriate for age. smiling. interacting. playing.
Skin: Warm, dry,
Head: Normocephalic. atraumatic.
Neck: Supple. trachea midline, pt with intermittent inability to turn neck to the left, accompanied by visible discomfort Passive ROM is restricted and elicits perceived pain with leftward rotation. Active ROM is intermittently normal, though patient appears hesitant to move the neck. Full active/passive neck flexion/extension. No meningismus. No visible swelling, masses, or signs of external trauma. No lymphadenopathy.
Eye: Pupils are equal, round and reactive to light
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm, no murmur
Respiratory: Lungs are clear to auscultation, no increased work of breathing
Gastrointestinal: Soft. Nontender. Non distended. No Hepatosplenomegaly.
Musculoskeletal: Normal ROM, no swelling
CBC, BMP, x-ray c-spine ordered.
WBC 10.64 HgB 8.7 Hct 28.3 Platelets 333
Na 134 K 4.5 Cl100 CO2 24 BUN 7 Cr 0.24 Glucose 122
Patient was given Motrin, but no notable change in exam after Motrin.
Xray c-spine: Apparent thickening of the prevertebral soft tissues with subglottic narrowing. If persistent clinical concern for retropharyngeal pathology, repeat lateral cervical spine radiograph with extension views or contrast-enhanced neck CT.
The decision to obtain CT neck soft tissue made.
If this is a retropharyngeal abscess, it is strange that he is afebrile with normal WBC and that there is enough inflammation to cause rotatory neck immobility, but no odynophagia/dysphagia or difficult with neck flexion/extension. I’m wondering if we should consult our old friend, the French otorhinolaryngologist Pierre Grisel! This smells like non-traumatic, rotatory, atlantoaxial subluxation s/p the recent otitis media — Grisel syndrome. The CT neck would assess for both the potential retropharyngeal process and the atlanto-axial subluxation.