More Severe Presentations

Patients usually only present to EDs with more severe forms of dystonia. Patients may appear agitated, with sweating and tachycardia.

Examples of such acute dystonias include:

Fig.4 Oculogyric crisis

Initial symptoms include:

  • Agitation
  • Restlessness
  • Fatigue
  • Fixed stare

This phase is followed by a more extreme and sustained spasm of extra-orbital muscles resulting most commonly in upward deviation of the eyes.

Additionally, the eyes may adduct. Abduction and downward gaze are less common.

Buccolingual crisis

Buccolingual crisis may include:

  • Trismus (an inability to open the mouth normally)
  • Risus sardonicus – a highly-characteristic, abnormal sustained grimace
  • Dysarthria (difficulties with articulation and speech)
  • Dysphagia (difficulties with swallowing)
  • Grimacing
  • Tongue protrusion or sensation of the tongue feeling swollen

The image shows risus sardonicus.

Trunk involvement


The image shows acute dystonia involving the trunk (opisthotonus).



Laryngospasm presents as stridor, and although rare, is potentially life threatening.

The image shows acute dystonia involving the larynx.

Learning Bite

Dystonias can involve any muscle group but most commonly involve the muscles of the head, neck and trunk. (Evidence Grade 2B)