Head Flashcards
Physical Assessment of the Head
- Look for torticollis
- Examine the head from above and side
- Examine the entire head using fingertips
- Feel for ridge over sutures
- Face
- Forehead and upper orbit
- Orbitonasal zygomatic area
- Maxillomandibular area
- Posterior cranial vault
- Examine the extremities and back of child with deformation of head since congenital dislocation, scoliosis and deformed feet are most common
Torticollis
Inability to turn head in both directions
Sutures (5)
Location
Metopic – frontal
Squamosal – above eye
Coronal – side suture closer to front of head
Sagittal – middle suture
Lambdoidal – side suture closer to back of head
**C before L**
4 problems seen with Head
Abnormalities of size
Abnormalities of shape
Positional problems
Abnormality of the scap
Abnormalities of Size (3)
Microcephaly
Macrocephaly (megacephaly)
Normocephalic
Macrocephaly Assessment
- Serial head measures
- Measure parents head
- Developmental hx
- Transilluminate skull
- Look for skeletal dysplasia (short stature)
- Listen for bruit
- Look for sunset eyes
- Signs of neurocutaneous disorder
Sunsetting eyes
With severe hydrocephalus, there may be forced, conjugate downward deviation of the eyes so that the inferior half of the iris is hidden by the lower eyelid, producing the “sunsetting” sign
See sclera above iris*
Causes of Microcephaly (6)
- Genetic defect
- Karyotype, chromosomal microarray
- Intrauterine infections
- Antenatal radiation
- Exposure to drugs and chemicals (antiepileptics)
- Perinatal insult
- Has been found in some cases to cause Cerebral palsy
Abnormalities of Shape
Scaphocephaly
Plagiocephaly
- Scaphocephaly or dolichocephaly
- Positional problems in the premature infant
- Saggital Craniosynostosis
- 24-25 weeks = premie head; outgrow it
- Plagiocephaly (just positional)
- Common with back head sleep position
- Torticollis
What happens when the sagittal suture closes too early?
Head grows long ways –> long narrow head
Craniosynostosis
Two main categories
- Rare condition in which the skull sutures close and the bony plates of the skull become fused too early in life.
- Craniosynostosis develops while the fetus is still in the mother’s womb
- 1 in every 2,500 births
- Sagittal suture closes prematurely
- Craniosynostosis can occur as a part of a larger pattern of abnormalities
- Two main categories:
- Simple or isolated craniosynostosis
- Complex or syndromal craniosynostosis
- Not Genetic**
Craniosynostosis
Make sure to….
Palpate all sutures and feel for overriding bones
Causes long, narrow head, frontal bossing
Scaphocephaly
- No growth in perpendicular to sagittal suture
- Bitemporal narrowing
- Cranial elongation in anterior-posterior direction
What is characteristic of Scaphocephaly?
Frontal bossing and prominent occiput
Brachycephaly
- Bilateral coronal or lambdoidal (11%)
- Broad skull with a short base and a recessed lower forehead.
- Caused by premature closure of the coronal suture on both sides of the head
- Brachy-, turri- or acrocephaly
- Associated with:
- Apert syndrome
- Crouzon syndrome
- Pfeiffer syndrome
Brachycephaly Characteristics
- High hat appearance
- Long, underdeveloped philtrum
- Downward slanting eyes
- Prominent epicanthal folds
- Tongue out – low tone
- Low set ears
Crouzon’s Syndrome (4)
- Craniosynostosis most often of the coronal and lambdoid and occasionally sagittal sutures
- Underdeveloped midface with receded cheekbones or exophthalmos (bulging eyes)
- Ocular proptosis which is a prominence of the eyes due to very shallow orbits
- Esotropia (inward turning eyes) and/or wide set eyes
- Shallow eyes/orbit
Apert Syndrome (4)
- Very high brachycephalic head
- Severe syndactyly affecting all limbs.
- Syndactyly involves bony fusion.
- Apert is the second most common craniofacial syndrome after Crouzon.
Fushion of fingers and toes!
Patients with Aspert Syndrome
- Brachiocephaly
- Very low set ears (know by matching up canthus and occiput)
Metopic Craniosynostosis
- Trigoncephaly
- Narrow, triangular, ridged forehead
- METOPIC CLOSED*
- Head tilted back
- Ocular problems
- Not urgent and does not have affect on brain growth
- Pointed at forehead; frontal bossing
Oxycephaly
5 characteristics
- Closure of all sutures except squamosal
- Surgery is URGENT
- Brachiocephalic
- Long philtrum
- Low set ears
- Frontal bossing
- DYSMORPHIC FEATURES*
Positional Plagiocephaly
- Face will be pushed forward on the affected side
- Frontal Bossing due pressure on the occiput
- The ear on the affected side will be forward in comparison to the unaffected side
- A parallelogram will be formed.
Flattening on one side of head – sutures are okay; more about positioning!
Lambdoidal Craniosynostosis
- If there is lambbdoidal synostosis, the head cannot expand in the frontal region on the affected side of the head so the growth will be affected on the unaffected side.
- Since there is growth restriction on the affected side, there is overgrowth everywhere else
- A trapezoid results.
Affected side has NO OPEN SUTURE* One side of face jets out
What characterizes a child with Crouzon Syndrome?
Multiple craniosynostoses
Bulging or proptotic eyes
Scalp
Waardenburg Syndrome
- White forelock
- Pointy chin (inverted triangle face)
- Beaked nose
- Normal IQ
- Busy eyebrows
- HEARING LOSS LATER IN LIFE!
Differentiating Alopecia Areata from Tinia Capitis
Clinicians rely on…
Key points (4)
While culturing is done, most clinicians rely on history and physical and do not wait to treat
Key points
- Age
- Black dot sign (HALLMARK)
- Race
- Pattern of hair loss
Tinia capitis = tiny mm that have dotting area for aleopecia – pattern = circular hair loss
Alopecia Areata (8)
- Usually patchy, can be multifocal
- Onset: Abrupt, waxes and wanes
- Appearance: Thin with abrupt bare patches, exclamation point hairs
- Prominent degree of shedding
- Any age, first usually before 20
- Positive pull test
- Personal or family hx of autoimmune disease
- Needs TSH
Tinia Capitis
- Specific area, focal or multifocal
- Onset = Gradual or abrupt
- None to some inflammation, scaling
- Degree of shedding = prominent
- Common in childhood; any age
- Positive pull test results
- Contact with animal with dermatophytes
Midface Hypoplasia (4)
- Associated with sleep apnea and stridor
- Dental problems
- May have hearing problems
- Face too together
Micrognathia
- The mandible has not grown as much as it should resulting in a small mandible and chin.
- Advancement of the mandible and advancement of the chin surgically.
- The correction is done via the intraoral route without any incisions on the face
- Preceded by orthodontic treatment to align the teeth prior to proper surgical treatment.
- MANDIBLE TOO SMALL = JAY LENO
Prognathic Mandible
When the lower jaw is too prominent
- Occurs with congenital overgrowth of the lower jaw
- Certain pathologic such as gigantism due to pituitary overgrowth and other tumors or congenital deformities
Temporomandibular Joint
- Place the tips of your index fingers directly in front of the tragus of each ear
- Ask the patient to open and close their mouth.
- Record any decreased range of motion, tenderness, or swelling
Presence of Vascular Marks or Masses
- Masses
- Dermoid cyst
- Bone cysts
- Loss of hair
- Scars
- Presence of infection
- Palpate to identify any areas of tenderless of deformity
Sturge Weber Syndrome
- Look for non elevated purple venous malformation in the distribution of trigeminal nerve involves ophthalmic division
- High incidence of mental retardation
- Ocular complications (glaucoma) on the affected side
Well demarcated area of redness; deformation in brain and can cause seizures* Can get it lasered away
How to assess the Salivary Gland
Parotid: palpate the gland and look at the angle of the jaw
Parotid Duct Orifices
Massage of the gland should produce….
- On the buccal mucosa opposite the upper second molar
- Massage of the gland should express clear fluid
- The submandibular and sublingual glands empty into the floor of the mouth.
Differential Diagnosis for Parotiditis
Wind parotiditis
Air is forced into parotid duct with glandular swelling from children learning to play a wind instrument or from blowing up balloons
Differential Dx for Parotiditis
Viral infection vs. Bacterial
- Viral causes include mumps, parainfluenza type I and 3, HIV, and other such as CMV, coxsackie
- Bacterial infections
- Staphylococcus aureus
- Streptococcus species
- Can have a tender and red gland with significant systemic symptoms
- Usually treated with Augmentin
Differential Dx for Parotiditis (3; including rare instances)
- Recurrent parotiditis is associated with pain, fever
- Abscess of parotid
- Much rarer: Cat scratch, TB and other such as tularemia as part of uveoparotid syndrome
Differential Dx for Parotiditis
Metabolic Causes
Will be slow, progressive, painless and lacking inflammation
Differential Dx for Parotiditis
Starvation
Obstructive enlargement
Autoimmune problems
- Starvation
- Hypoproteinemia
- Anorexia
- Cushing syndrome
- Hypoproteinemia
- Obstructive enlargement
- Seen with stones
- Autoimmune problems
- Lupus with recurrent swelling as an initial presentation
- Sjogren syndrome
- DRY EYES/MOUTH
- (keratoconjunctivitis sicca and xerostomia with or without parotid swelling).
