Although nonspecific, white blood cell count, ESR, or C-reactive protein levels will be elevated in most children with these conditions, as well as those with other infections of the head and neck (e.g., tonsillitis, mastoiditis) Finally, an upper lobe pneumonia identified on chest radiograph may be the cause of neck stiffness in the febrile child In the afebrile child with neck stiffness, a cervical mass within the SCM may be present In an infant, this suggests congenital muscular torticollis, and neck ultrasound may be diagnostic An SCM hematoma or tear may present with an SCM mass in an older child If the cervical mass is not within the SCM, a malignancy or atypical infection may be the cause A complete blood cell count, imaging, tuberculosis screening, and biopsy of the mass should be considered For the afebrile child with no cervical mass, an abnormal neurologic or ophthalmologic examination suggests a brain tumor, subarachnoid hemorrhage, other space-occupying lesions, or visual or vestibular disturbances causing the abnormal neck posture In these situations, the patient does not have primary neck pain or stiffness but is attempting to correct these disturbances through changes in head position In addition to careful neurologic and ophthalmologic examinations, a head CT or MRI scan may be necessary to evaluate for space-occupying lesions of the brain Additionally, a lumbar puncture may be necessary to exclude subarachnoid hemorrhage, idiopathic intracranial hypertension, or Guillain–Barré syndrome If myasthenia gravis is suspected, a neurologist should be consulted Children with torticollis due to dystonic reactions after receiving neuroleptic or antiemetic medications will usually respond to intravenous diphenhydramine Timing of symptoms may be helpful in determining the appropriate evaluation of children with neck stiffness without fever, cervical mass, or abnormal ophthalmologic or neurologic examination Chronic symptoms may suggest a congenital syndrome, collagen vascular disease, Sandifer syndrome, spasmus nutans, or a neoplastic process Children with these conditions may also present with acute onset of symptoms Some children with neck stiffness may have dysmorphic features, suggesting specific skeletal malformation syndromes Radiographic imaging may help detect additional diagnoses such as osteoid osteoma or other benign tumors of the head and neck If symptom onset is acute and the patient appears well, muscle spasm may be the cause of torticollis For the well-appearing child with sudden onset of mild torticollis without a history of trauma or fever and with a normal neurologic examination (e.g., the child who awakens with mild torticollis after sleeping in an unusual position), nothing more than careful clinical assessment, analgesic/anti-