A one-year-old is brought into the ER with a head tilt and gradually worsens over a few days with ptosis of right eyelid and inability to walk.
You quickly review the chart, finding no significant past medical history (except for being overweight) and call the mother back. You quickly screen the child's symptoms for red flags, and decide that she can wait to be seen in the afternoon.
A subtle tilt
In the past month she has had two URIs and was recently diagnosed with otitis media at a local emergency department (ED) three days ago, where she was prescribed amoxicillin. Her mother tells you that her daughter hasn't had any recent travel, fevers, trauma, previous head tilt, or behavioral changes. She was born at full term without complications, and is up to date on all her vaccinations, save for her 1-year-old shots. She is in daycare three days a week.
Her ear, nose, and throat exam are benign with the exception of some remaining fluid behind the left eardrum. Her eye exam is normal, with full range of motion, no nystagmus or strabismus. Her oral mucosa is moist and there are no oropharyngeal lesions or tongue fasciculations. Her posterior pharynx is completely benign. Her head was mildly rotated to the right, with some left-side bending. You feel no lymphadenopathy or thyromegaly, while making a mental note that deeper cervical adenopathy may be concealed. There is no knot in the sternocleidomastoid muscle.
You are able to straighten out her head with passive range of motion, and it seems that her "torticollis" has now vanished. Heart sounds are normal, no heart murmur is heard. Breath sounds are clear, and her abdominal exam is completely benign without any masses or hepatosplenomegaly.
The genitalia are normal. There are no rashes. Her neurology exam included 2/4 deep tendon reflexes in all extremities. Muscle bulk was normal, and she exhibited normal muscle strength throughout. Her gait was that of a normal 1-year-old. Her cranial nerves were all intact. Her facies was symmetric.