Grisel Syndrome in Pediatric Age: A Single-Center Italian Experience and Review of the Literature

Retrospective analysis of atlantoaxial rotatory fixation describing age distribution and gender ratio in children and adolescents: A preliminary report

INTRODUCTION

Atlantoaxial rotatory fixation (AARF) in children presents with an acute onset of neck pain. Almost all cases heal within a few days of onset and are treated conservatively. Because few cases of AARF have been reported, the age distribution or gender ratio of AARF in the child population have not been described enough. In Japan, the social insurance system covers all citizens. Thus, we used insurance claims data to investigate the features of AARF. The aim of this study is to examine the age distribution, compare gender ratio and determine the recurrence proportion of AARF.

METHODS

We used the JMDC database to search for claims data submitted between January 2005 and June 2017 for cases of AARF in patients aged <20 years.

RESULTS

We identified 1949 patients with AARF, of which 1102 (56.5%) were male. The mean age was 98.3 ± 42.2 months and 91.6 ± 38.4 months in males and females, respectively, and males with AARF were significantly older at onset than females with AARF (p < 0.001). In both sexes, the highest frequency of AARF occurred when the patient was 6 years old. There were 121 (6.2%) cases of recurrent AARF (male: 61, 5.5%; female: 60, 7.1%), but the age differences between the sexes in these cases were not statistically significant.

CONCLUSIONS

This is the first report to describe the characteristics of the study population of AARF. Males were more likely to suffer from AARF than females. Furthermore, age (in months) at AARF onset was significantly higher in males than in females. Recurrence rate was not significant in both sexes.

A pictorial review of imaging findings associated with upper cervical trauma

The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.

Challenges in Grisel's Syndrome Management in a Two-Month-Old Infant

Grisel's syndrome (GS) is a rare neurosurgical condition involving nontraumatic rotatory subluxation of the atlantoaxial joint. This case report presents a two-month-old infant girl, the youngest reported case of this syndrome based on our literature review to the date of this publication. The infant was initially referred to our hospital as a case of the arachnoid cyst but was subsequently neuroradiologically diagnosed with GS, which was believed to be secondary to a retropharyngeal abscess. After developing weakness and developmental delay as well as failing conservative management for two years, the infant underwent C1 laminectomy and occipitocervical sublaminar wire fusion with favorable outcomes. GS should be considered a differential even if the patient does not present with typical signs such as torticollis and neck pain. If not identified early and treated effectively, it can result in severe neurological damage. The management plan largely depends on the Fielding-Hawkins grade of subluxation and the timing of diagnosis.

Hyaluronic acid augmentation pharyngoplasty complicated by retropharyngeal abscess and grisel syndrome: Case report and literature review

Augmentation pharyngoplasty, in which tissue filler or grafts are used to augment the posterior nasopharynx, is an accepted option to treat velopharyngeal insufficiency. It is generally well tolerated and safe with limited side effects. In this study, we describe a case of a retropharyngeal abscess and Grisel syndrome following hyaluronic acid augmentation pharyngoplasty. Grisel syndrome is a serious condition that requires early diagnosis and prompt intervention to prevent further complications.

Velopharyngeal insufficiency (VPI) can be treated conservatively by speech therapy or surgically by augmentation pharyngoplasty and pharyngeal surgeries. Augmentation pharyngoplasty is safe and well‐tolerated procedure. We report a very rare complication of this procedure which is retropharyngeal abscess and Grisel syndrome (GS). GS is a serious condition that requires early diagnosis and prompt intervention to prevent further neurological complications.

Torticollis in childhood-a practical guide for initial assessment

Torticollis is encountered often in the paediatric setting and should be considered a presenting symptom, rather than a diagnosis. Aetiologies of torticollis are numerous, and the nomenclature describing underlying diagnosis can be confusing. Furthermore, children with torticollis typically present in the first instance to primary or secondary care rather than to the subspecialist. These factors can contribute to erroneous treatment of this patient-group which could be time critical in some instances. In this review, we discuss the common causes for torticollis and propose a simple clinical assessment tool and early management scheme that will assist in the differential-diagnosis and treatment pathway of this challenging condition.Conclusion: Torticollis can be the initial presentation of various conditions. The diagnosis and management tools provided in this article can aid in guiding paediatricians as to the correct initial management, imaging, and specialist referral. What is Known: • Torticollis in childhood is a very common presenting symptom with numerous aetiologies. • Management is complex, requires multiple clinical and imaging examinations, and is usually performed by non-specialized professionals. What is New: • A new, simple clinical-assessment tool under the acronym PINCH designed to aid paediatric general practitioners in diagnosing correctly the aetiology of torticollis. • A practical management scheme to aid in the treatment pathway of children with torticollis.

Mild Grisel Syndrome: Expanding the Differential for Posttonsillectomy Adenoidectomy Symptoms

BACKGROUND

Tonsillectomy with or without adenoidectomy is the second most common pediatric surgical procedure in the United States with up to 97% performed as an outpatient.1,2 While it is largely a safe procedure, several complications have been described and are encountered in the emergency department and primary care setting.

PRESENTATION

A 29-month child presented to the emergency department with neck stiffness 10 days after tonsillectomy and adenoidectomy. A computed tomography scan of the neck limited by motion artifact was unrevealing, but a consult to the pediatric otolaryngologist generated concern for Grisel syndrome, the atraumatic rotary subluxation of the atlantoaxial joint. While surgical intervention can be required, the patient had an uncomplicated clinical course and the anomalous neck posture resolved with time and antiinflammatories alone.

CONCLUSIONS

Keeping a broad differential for posttonsillectomy and adenoidectomy patient concerns is important for the clinician. Serious, life-threatening complications can arise from Grisel syndrome while good functional outcomes can be achieved with timely and appropriate treatment.

Grisel's syndrome associated with mumps: A case report

Grisel's syndrome (GS) is defined as atlantoaxial rotatory subluxation/fixation not associated with trauma or bone disease, usually following head and neck infection/inflammation or ear, nose, and throat (ENT) surgery. Many conditions could lead to Grisel's syndrome, of which mumps is rarely to be seen. This report discusses a case of GS in children with Type I atlantoaxial joint subluxation and previously diagnosed mumps. A 6-year-old boy who had cervical pain and torticollis for 2 weeks was admitted to our hospital. There was no trauma and he had not had ENT surgery but was diagnosed with mumps 2 weeks previously due to swelling of the left cheek and cervical lymph node. Physical examination and computed tomography confirmed a diagnosis of Grisel's syndrome with an ADI (atlanto-dens interval) of 1.6 mm. The patient then received occipito-mandibular traction for 6 days and recovered. No recurrence was observed at 1 year follow-up. Physicians should raise awareness of this rare complication of mumps to avoid life-threatening neurological impairments owing to Grisel's syndrome.

Torticollis as a Sole Presentation of Spondyloarthritis in a 4-Year-Old Child

Spondyloarthritis presents in various and occasionally unusual ways that imitates other diseases. Without forthcoming risk factors, such atypical presentation may elude diagnosis for months. The case presented here of a child, aged 4 years, who is negative for human leukocyte antigen B27 (HLA-B27) and with no family history of HLA-B27 related disease, who developed torticollis with neck pain and lymphadenopathy, highlights the necessity of continually evaluating a diagnosis, especially when treatment fails to produce expected results. Painful torticollis in a child with adenopathy often is infectious in nature or potentially due to Griesel syndrome when persistent. Chronic arthritis of the cervical spine may enter the differential diagnosis when torticollis is persistent, and early recognition and aggressive treatment is necessary to prevent permanent functional impairment.

Grisel's Syndrome in Children: Two Case Reports and Systematic Review of the Literature

Background and Objective. Grisel's syndrome is a rare syndrome characterized by nontraumatic rotatory subluxation of the atlantoaxial joint. It usually affects children and typically presents with torticollis after ear, nose, and throat (ENT) surgery or head and neck infections. In the pediatric literature, there is only a small amount of available data; moreover, no systematic review has been previously done with focus on the pediatric population. We report our experience of two cases, and we provide a systematic review on Grisel's syndrome in children in order to offer a deeper insight about its clinical presentation, its current diagnosis, and principles of treatment. Case Reports and Review. We describe two boys of 9 and 8 years old, who developed atlantoaxial subluxation after adenoidectomy. Considering the early diagnosis, a conservative treatment was chosen, with no recurrence and no sequelae at follow-up. We identified 114 case reports, of which 90 describe children, for a total of 171 pediatric patients. Of the 154 cases in which cause was reported, 59.7% presented a head and neck infection and 35.7% had previous head and neck surgery. There is no sex prevalence (49.7% males versus 50.2% females). Mean delay in diagnosis is 33 days. Eight % of the patients had neurological impairment of the 165 cases which mentioned treatment, 96% underwent a conservative treatment, of whom the 8.8% recurred with the need of surgery. As a whole, 12% underwent surgery as a first- or second-line treatment. 3 6% of the patients whose follow-up was reported developed a sequela, minor limitation of neck movement being the most frequent. Conclusion. Grisel's syndrome should be suspected in children with painful unresponsive torticollis following ENT procedures or head and neck inflammation. CT scan with 3D reconstruction is the gold standard for diagnosis, allowing the identification of the subluxation and the classification according to the Fielding–Hawkins grading system. Surgical treatment is indicated in case of high-grade instability or failure of conservative treatment. Review of the literature shows how early diagnosis based on clinical and radiological evaluation is crucial in order to avoid surgical treatment and neurologic sequelae.

Grisel's syndrome in Kawasaki disease

Background

Approximately 50–70% of patients with Kawasaki disease (KD) could present with cervical lymphadenopathy associated with deep neck inflammation, which may result in Grisel’s syndrome (GS). Given the possibility of neurological impairment owing to GS, it is important to understand the disease profile in KD. Therefore, we carried out this study to investigate this possible complication of KD, with the aim of improving pediatricians’ recognition and awareness.

Methods

Patients with KD complicated by GS in our hospital were retrospectively recruited for our study. The profiles of patients with GS (n = 10) were compared to those patients without GS (n = 1254). All the available literature describing these complications of KD was reviewed.

Results

The incidence of GS in KD was 0.6% in our population. Compared to patients without GS, KD patients with GS were older, presented with a significantly lower male:female ratio, and a higher incidence of cervical lymphadenopathy, a higher level of neutrophil count, and erythrocyte sedimentation rate. Ten articles reporting 14 KD patients with GS were reviewed. Of the total 24 patients, GS affected 7 males and 17 females, aged from 3.5 to 9 years old. Encouragingly, no delayed diagnosis and treatment of KD was found, and all patients received conservative therapy for GS, without intravenous immunoglobulin resistance, coronary artery lesions, and neurological impairment.

Conclusions

GS is a rare complication of KD with an incidence of 0.6%, predominantly affecting older, female children. The overall outcome of this disorder in KD was satisfactory with conservative therapy. Pediatricians, especially pediatric surgeons, should recognize and be aware of this possible complication of KD to avoid misdiagnosis and overtreatment.

Atlantoaxial subluxation secondary to retropharyngeal abcess in adults (Grisel's syndrome). Review of literature about a clinical case

Grisel syndrome (GS) is a non-traumatic atlanto-axial subluxation produced after an inflammatory, infectious or postsurgical process of the upper neck region. It is a characteristic, although currently uncommon complication of acute bacterial pharyngitis in the pediatric age. Presentation in adults is even more infrequent and requires specific management. We present the case of a 68-year-old patient with a history of chronic myeloid leukemia, who presented with infectious polyarthritis, cervicalgia, torticollis and cervical impotence. Cervical radiography, CT, and MRI showed a C1-C2 subluxation adjacent to a pharyngeal abscess, so GS was diagnosed. After antibiotic therapy, the patient had to undergo surgery due to the failure of the closed reduction. Due to its low incidence, there are no clinical guidelines for the management of these patients; The interdisciplinary collaboration is fundamental to establish the opportune diagnosis that allows to establish the conservative treatment and prevent the surgery, as well as the complications and sequelae of the fixation of the atlanto-axial joint.