vestibular dysfunction and head tilt

I am a physical therapist treating a two year old little boy being worked up for a vestibular dysfunction.  He has an intermittent head tilt to the right that varies in degrees from day to day.  He had one episode of "passing out" that was preceded by an excessive amount of head tilting.  His neurologist believes that the head tilt is torticollis.  The child has full active cervical rotation which would be unusual in true congenital muscular torticollis.  No cervical spine xrays have ever been taken.  His head MRI revealed an assymetry in the sizes of the lateral ventricles, but the mother stated that this was a normal variation.  He had two positive results on a vestibular rotation test.

Do you feel that a diagnosis of CMT can be made without a cervical spine xray?
Do you feel that this child's head tilt may be neurologically based rather than orthopedically based?
What other special tests would you recommend?

[CCF Neuro[P] MD, RPS]

Dear Judy:

I am assuming that the child has had the torticollis since birth?  The usual differential is congenital torticollis due to fibrosis of the sternomastoid muscle that was probably traumatic in origin.  However, we try and distinquish this from neurological, vertebral or ocular causes, which include inter alia, superior oblique palsy, posterior fossa tumors and osteoarticular lesion of the cervical column.  Since the child is two, the spontaneous disappearance occurring at the end of the first year of life is likely not not happen.  The episodes sound like benign paroxysmal torticollis of infancy, with vertigo and head tilt.  Since the MRI should also give a view of the cervical vertebrae (albeit not a great view) maybe the neuroradiologist thought it looked normal. The MRI would also rule out a posterior fossa tumor. I assume that a opthalmological exam by a pediatric opthalmologist has been done. So, it does sound like it is the benign variety.  We have also seen this entity in the setting of migraine headache variant.  A rare but not so uncommon finding with a family history.  

It would be nice to examine the child.  I think I might do a cervical x-ray, but then I am at the cleveland clinic and tend to do alot of tests.  I am sorry I am not much help.

Sincerely,

CCF Neuro MD