Neonatal Advanced Assessment: Head, Neck, Eyes, Ears, Nose, Mouth Flashcards
The shape of an newborn’s head usually relates to what?
Molding of the skull during delivery.
How does C-section head molding appear?
Head will appear well-rounded.
How does Breech head molding appear?
The head will appear egg shaped; molded posteriorly; prominent occiput.
How does prolonged “diagonal pressure” during labor effect the newborn’s head shape?
Causes it to appear “out of round” shape.
Asynclitic
What should you tell a parent who is worried about the shape of their newborn’s head after delivery?
You can reassure parents that molding associated with in-utero pressures or labor can be expected to self-correct within days to weeks.
When inspecting the skull during an assessment what do you assess?
Head bones, sutures (fibrous joints), and fontanels
Where is the Metopic Suture Located?
The metopic suture extends midline down the forehead inbetween the two frontal bones and intersects with the coronal suture.
Where is the anterior fontanel (AF)?
The anterior fontanel is located at the intersection of the metopic, saggital, and coronal sutures.
What is the standard size for the anterior fontanel (AF)?
Common 0.6-3.6 cm
African Americans; larger @ 1.4-4.7 cm
How do you measure fontanels?
Diagonally from BONE to BONE
What are fontanel measurements useful for?
Used only for a baseline for serial measurements.
If during an assessment you are unsure if a fontanel is flat or bulging, how should you adjust your assessment approach?
Re-assess fontanel with infant sitting in an upright position.
A sunken fontanel is a sign of what?
Severe dehydration; excessive decompression in an infant with a newly placed Ventricular drain or VP shunt.
What is a large anterior fontanel associated with?
Hypothyroidism
When does the anterior fontanel typically close?
6-24 months
What should you auscultate for when assessing an infant’s head and neck?
Which infants, is auscultation especially indicated for?
Auscultate over the fontanels and lateral skull bones for an audible bruit.
In the normal infant a bruit can be normal
However, In Infant’s with hemangiomas or heart failure, a bruit can be a sign of AV malformation.
Where is the saggital suture located?
The saggital suture is located midline between the two parietal bones extending to the posterior fontanel (PF) .
Where is the posterior fontanel (PF) formed?
The PF is formed at the intersection of the saggital suture and the lamboidal suture. Seperates the parietal bones from the occipital bones posteriolaterally.
What size if the Posterior Fontanel (PF) normally?
In caucasions it is usually about 0.5 cm
In African Americans it is usually about 0.7 cm
When does the Posterior Fontanel (PF) usually close?
The PF closes at approximately 2-3 months
Where is the “third” fontanel located?
Why does it occur?
What types of babies have this as a normal variant?
The “third” fontanel occurs along the saggital suture lines inbetween the AF and the PF.
This is a defect of the parietal bones and not a true fontanel.
Can be normal variant with Down syndrom or congenital hypothyroidsim.
Where is the Squamosal Suture located?
The Squamosal Suture extends above the ear to seperate the temporal bones from the parietal bones.
Usually only able to be palpated in babies that are premature or have hydrocephalus.
Where are the sphenoid and mastoid fontanels located?
The sphenoid fontanel seperates the Frontal bone from the Temporal bone. Forms at the coronal suture and the squamosal suture.
The Mastoid Fontanel separates the temporal bone from the occipital bone. Forms at the squamosal and lamboidal suture.
What is a normal amount of seperation between sutures?
Sutures may be seperated up to 1 cm.
How do you assess the mobility of sutures?
Gently plaec thumbs on the bones on either side of the suture and gently press down alternately with one thumb and then the other.
How do you differentiate an overriding suture from an immobile suture?
A suture that peaks and is immobile implies fusion of the suture. (Craniosynostosis)
What happens when there is a premature closure of a suture?
Bone growth stops perpindicular to the suture, but allows continued parallel growth and compensatory expansion at the functional sutures. Leads to an abnormal shaped head.
What do fused coronal sutures limit?
Fused Coronal sutures limit forward growth. Leads to a broad skull.
Brachycephaly
What does early closure of the saggital suture limit?
Limits lateral growth; skull will be long and narrow;
Scaphocephaly
Plagiocephaly results from what?
asymmetric skull shape resulting from closure of sutures on one side of the head.
What head shape will result from this?
Plagiocephaly
What can Craniosynostosis be associated with?
- Genetic syndromes such as Apert or Crouzon
- Metabolic disorder from hyperthyroidism
What is dolichocephaly?
Flattened on each side of head. “toaster head”
What are areas of soft thinning skull bone called?
Craniotabes
Will feel collapse and recoil of bone with assessement and snapping sensation.
Where is craniotabes usually located?
How does it develop?
Craniotabes is usually located at parietal bones near the saggital suture.
Usually due to prolonged vertex engagement
Or
Pressure of the fetal head on the uterine fundus with breech position
What is the incidence of craniotabes and what else is associated with it?
Craniotabes is seen in up to 30% of normal newborns.
Associated with rickets, osteogenesis imperfecta, congenital syhpillis, and Vit D deficiency
Does Craniotabes resolve?
Craniotabes will resolve in a few weeks if it is due to external pressures on the bones and not a metabolic or underlying disease process.
What is the most common kind of birth trauma to a newborn’s head?
Caput Succedenum
Crosses suture lines; Edema pits with pressure; poorly defined edges; caused by pressure that restricts the return of venous lymph flow during labor and delivery.
Resolves within a few days
Describe the differences between Caput and Cephalhematoma
Caput: Collection of edema due pressure that restricts the return of venous and lymph flow during labor and delivery. *crosses suture lines; edema pits, poorly defined edges, most common birth trauma to head; resolves within a few days.
Cephalhematoma: collection of blood between periosteum and the skull
*Demarcated edges; confined by suture lines; with time may liquify and become fluctuant on palpation; usually located on parietal and occipital bones; Can take weeks to months to resolve.
Describe a Subgaleal Hemmorhage.
Third and most serious lesion from birth trauma
Most common with vaccum assisted delivery
Presents with generalized scalp edema with ecchymosis; bilateral or unilateral periorbital and periauricular edema
Crosses suture lines and can be manually repositioned from the eyebrows to the nape of the neck.
What type of birth trauma is this?
Subgaleal Hemmorhage
What is effective treatment for a subgaleal hemmorhage and what does this treatment prevent?
Fluid resuscitation; blood replacement; and treatment of abnormal clotting factors
Prevents severe anemia; hypotension; and death from occuring.
If a baby has a trauma to the scalp how should it be described in documentation?
The lesion should be described by appearance, size, location near sutures, fontanels, and underlying bones.
What is aplasia acutis congenita?
Uncommon scalp lesion found primarily at the vertex just in front of the lamba.
Hairless; circumscribed area of 1 cm or less; surface shiny;cicatricial (new tissue that forms over a wound and later contracts into a scar); flat or keloid in appearance.
What is a soft, shiny, hairless, keloid like lesion that may occasionally blister or ulcerate?
Acutis Aplasia
What is acutis aplasia associated with?
Infant will have risk for underlying defect and associated major defects (Trisomy 13).
Needs careful evaluation for other abnormalities.
What is an ecephalocele?
Malformation of the skull associated with incomplete nueral tube closure.
CNS tissue can protrude from the defect ANYWHERE on the skull.
Most Commonly MIDLINE and in OCCIPUT area.
When assessing for scalp hair what should you assess for?
Quantity; texture; brittleness; distribution; hair whorls
A low hairline, increased quantity of hair, and brittleness may be associated with what?
Congenital Anomolies
What is the slope of each hair follicle associated with?
Associated with the stretch of the skin during rapid brain growth during gestational weeks 10-16.
How many hair whorls is considered a normal finding?
1-2
What is an abnormally placed whorl, absence of hair whorl, or unusual hair growth associated with?
Abberant Brain Growth and Mental Retardation
What is alopecia?
A diffuse or focal absence of hair; abnormal deficiency of hair
What is diffuse alopecia more commonly associated with?
Genetic anomolies in the hair follicles or is syndromic
What is Focal Alopecia Associated with?
traumatic or associated with underlying scalp lesions.
What is Hursitism?
Excess hair growth
May be genetic, syndromic, metabolic, drug induced, or an isolated finding.
What is fundamental for the adequate assessment of head size?
The OFC (Occipital-Frontal-Circumference)
What is the best method for obtaining the OFC measurement?
Measure at the widest occiput prominence and anteriorly 1-2 cm above the glabella space at largest frontal prominence.
Taken three times with the LARGEST of the three recorded.
What is the average OFC at 40 weeks gestation?
35 cm
What is the range of the OFC from the 10-90th percentile?
33-37 cm
Prior to fontanel closure, what is the OFC an indirect measure of?
An indirect measurement of the brain, CSF fluid, cerebral blood volume, and bone.
Why is OFC, weight, and length for gestational age plotted and monitored?
To assess for symmetric vs asymmetric growth restriction and micro and macrocephaly.
What is Symmetrical Growth Restriction?
Consdiered Global Growth Restriction. Seen less common (20-25%). Indicates that the fetus developed slowly throughout pregnancy and affected from a very early stage. The head circumference is in proportion to the rest of the body.
Since most neurons are developed by the 18th week of gestation, the fetus with symmetrical IUGR is more likely to have permanent neurological sequela.
What are common causes of symmetrical growth restriction?
Common causes include:
- Early intrauterine infections, such as cytomegalovirus, rubella or toxoplasmosis
- Chromosomal abnormalities
- Anemia
- Maternal substance abuse (prenatal alcohol use can result in Fetal alcohol syndrome)
What is asymmetric growth restriction?
Seen most common (70%).
Restriction of weight followed by length. Head Grows normally.
A lack of subcutaneous fat leads to a thin and small body out of proportion with the head. (Protective Mechanism)
In these cases, the embryo/fetus has grown normally for the first two trimesters but encounters difficulties in the third, sometimes secondary to complications such as pre-eclampsia.
The baby is at increased risk of hypoxia and hypoglycaemia.
What are common causes of Assymetric Growth Restriction?
Caused by Extrinsic factors:
- Chronic high blood pressure
- Severe malnutrition
- Genetic mutations, Ehlers–Danlos syndrome
How is Microcephaly Classified?
OFC less than 2 standard deviations (SD) below the mean for gestational age.
Less than 3rd percentile
Can be isolated finding or associated with genetic syndrome or congenital infection.
What is microcephaly usually associated with and what causes it?
microencephaly; reduced brain growth?
What typically happens with microcephaly?
The sutures often become prematurely fused because of the expansive force of brain growth that enlarges. The cranial vualt is lacking.
What are common gender and racial variations seen with the OFC?
Females tend to have smaller OFC’s than Males
African Americans have smaller OFC than Whites.
What is Macrocephaly?
Diagnosed when the OFC is above the 90th percentile despite appropriate weight and length for gestational age.
May be familial; caused by hydrocephalus; or associated with dwarfism or osteogenesis imperfecta.
How do you confirm Macrocephaly?
Obtaining measurements of the parents heads and plotting them on the Weaver Curve.
When is transillumination of the skull helpful in a normal newborn assessement?
Transillumination is helpful when the infant’s head has an unusual shape or size, or the neurologic examination is abnormal.
How do you use transillumination in a newborn assessment?
Place it flat against the infant’s head in a dark room.
A ring of light more than 2 cm larger than the light source implies increased fluid or decreased brain tissue.
When can you see a false positive transillumination?
May occur with a large caput because the scalp edema will transmit a halo of light.
If there is a high suspicion for hydrocephalus after using the transilluminator or in general what more definitive testing should be ordered?
Cranial ultrasound; CT; MRI
How should the face examination begin?
Examine the relationship between the ears, eyes, nose, and mouth.
When assessing the forehead what relationship to the face should you see?
The forehead should take up half of the face; reflects the large cranial volume needed for rapid brain growth.
How does the upper, mid, and lower face evolve overtime to produce adult like face proportions?
During childhood, the mid- and lower face exceeds growth of the upper face.
What should be noted during the facial exam?
Evidence of trauma, shape and symmetry of the face.
What can cause facial bruising, petechiae, and progressive edema of the face?
Face brow presentation at birth or the presence of a nuchal cord at delivery.
Unusual flattening of the facial features at birth can be a result of what in utero?
Prolonged intrauterine compression from OLIGOHYDRAMNIOS
What can forceps delivery cause?
Bruises, abrasions, and fat necrosis
Anatomy of the Ear
Antihelix
Anatomy of the Ear
Concha
Anatomy of the Ear
Helix
Anatomy of the Ear
Tragus and Antitragus
Anatomy of the Ear
Triangular Fossa
What can cause facial paralysis after birth?
Damage to the facial nerve
What type of facial paralysis is most often seen?
Paralysis of the mandibular branch of the face which controls the lips.
Will see decreased movement on the AFFECTED side of the face when the infant cries.
With facial paralysis, if the damage was caused by pressure, when can you expect it to resolve?
Within hours to weeks after birth
How do you differentiate facial paralysis with Assymetric Cyring Facies (ACF)?
Facial Paralysis babies will have loss of forehead wrinkling and nasolabial folds, partial closing of eye on affected side
In ACF, there is congenital hypoplasia or absence of the depressory anguli oris muscle (DAOM).
If a baby has Assymetric Crying of Facies (ACF) what else is this associated with?
Cardiovascular anomolies
Abnormal formations or placement of the ear can be associated with what?
Chromosomal anomolies and syndromes
Hairy ears involving both the pinna and lobes are associated with what?
Familial, syndromic or associated of mothers of poorly controlled diabetes.
Minor malformations of the ear such as pits or skin tags tend to be familial or associated with other anomolies and thought to be remnants of what?
Thought to be embryologic remnants of the first brachial cleft or arch
Where are minor ear malformations such as pits and skin tags are usually located where?
Usually anterior to the tragus.
If you see a periauricular sinus on the ear what should you consider when assessing it?
It may be blind or communicate with the internal ear or the brain.
What is a Darwinian Tubercle?
A small nodule on the upper helix.
A poorly formed external ear should alert the examiner to what?
Possible chromosomal anomalies or syndromes
How can you assess the position of the external ear?
Draw a line midline from the inner to the outer canthus of the eye toward the ear.
If the insertion of the ear falls below this line, they are considered low set ears.
How should you inspect the ear canal?
Inspect the ear canal visually to assess presence and patency. Otoscopic evaluation can be done later at first well baby visit.
What is one of the most common major abnormalities of the ear present at birth?
Hearing Loss
Universal hearing screening is recommended for all newborns
Goal of intervention by six months of age.
What does conjunctival or subconjunctival Hemmorhage result from?
Rupture of the capillaries in the mucous membrane that lines the eyelids. and is reflected onto the eyeball (conjunctiva)
Seen as a bright red area of the sclera near the iris.
When do conjunctival hemmorhages usually resolve?
Within one week to ten days
What is a Coloboma?
Malformation of the eye where an absence or defect of some occular tissue (including the eyelid) may be seen.
What can Coloboma be associated with?
CHARGE Syndrome
C-Coloboma
H- Heart Disease
A-Atresia of Choanae
R- Retarded growth and development
G- Genital Anomolies
E- Ear deformities/deafness
What is Nevus Simplex?
A common birthmark seen on the eyelids and glabella.
How do you differentiate between a nevus simplex and a port wine stain?
Nevus simplex will blanch but port wine stain will not.
When do tears usually start to form?
2-3 months of age
When does the nasolacrimal duct become fully patent?
5-7 months
Because of this purulent or mucoid eye drainage in the Absence of other inflammation, redness, or swelling is normal.
What should you do if a baby has purulent or mucoid eye drainage without any other signs of redness, swelling, or inflammation.
Treat with lacrimal massage and gentle cleansing with water and a cotton ball.
Inform parents that this can be normal and can occur because the nasolacrimal duct isn’t fully developed until 5-7 months of age.
The distance between the outer canthi can be divided into what?
Equal Thirds
Hypertelorism
Eyes widely spaced
Hypotelorism
Eyes more closely spaced
Why are eyes are considered upslanting?
The outer canthus is higher than the inner canthus
What is the epicantheal fold?
vertical fold of skin on either side of the nose that covers the lacrimal caruncle. Usually disapears by 10 years old. Except in asians.
What is the palpebral fissure?
The opening in between the eyelids.
How do you know if eyebrows are normal?
Eyebrows normally extend along the palbebral fissure.
Eyebrows that meet at the glabella or are abnormally long and tangled can be a sign of :
Cornelia de Lange Syndrome
When using the opthalmoscope what should the examiner look for?
Equal, Brisk constrictive-reactive pupils; the orange, yellow, red reflex
What interupts the red reflex?
Opacity of the lens or cornea (luekokoria or white retinal reflex)
Lacking a red reflex can indicate what?
congenital cataracts, retinoblastoma, or glaucoma
How can the red reflex appear in dark skinned infants?
Orange, yellow or grayish.
What colors will the Iris be in newborns
Dark gray, blue or brown
Final pigmentation is acquired at six months of age
What are brushfield spots?
White speks scattered linearly around the entire circumference of the iris.
Associated with Downs Syndrome but can also be seen as a normal variant.
A blue colored sclera is associated with what?
Osteogenesis Imperfecta
When does horizontal nystagmus associated with rapid movement disappear?
3-4 months
Spontaneous horizontal, vertical, torsional, and persistent nystagmus are associated with what?
Are abberant findings; associated with visual or neurological abnormalities
What is Strabismus?
Muscular incoordination giving the appearance of cross eyes
What is psuedostrabismus?
flat nasal bridge or epicantheal folds that can make the eyes appear crossed.
Can be differentiated from actual strabismus by the presence of symmetric corneal light reflexes.
Proptosis
Abnormal protrusion of eye; associated with hyperthyroidism; tumors; hemangiomas; congenital glaucoma; and can be associated with damage to the eye with hemmorhage.
Nose shapes are racially and familialy varied.
However, a very low nasal bridge with a broad base can be associated with what?
Down Syndrome
A deviation of the septum can be a deformation from position in utero. What must the examiner rule out in this instance?
Dislocated septum which would require treatment.
The examiner can push the nose to midline and if the septum does not straighten easily, and the nares remain asymmetric- Dislocated septum is likely.
How does Choanal Atresia Present?
Infant will be cyanotic at rest due being obligate nose breathers; Pink when crying due to breathing thru the mouth
What is microstomia?
Small mouth opening
What is Macrostomia?
Large mouth opening assocaited with storage diseases like mucopolysacchraridosis.
A bifid uvula is associated with what?
submucosal cleft, notched hard palate, and muscular diastasis of the soft palate.
What is macroglossia associated with?
Beckewith Weideman; hypothyroidism; and mucopolysaccharidsosis.
White patches on the tongue and mucous membranes may be from what?
residual milk, leukoplakia is normal in darkly pigmented infants.
If an infant is tongue tied what can you see?
V shape of tongue
What is a translucent or bluish swelling under the tongue called?
Mucocele or Ranula
It is a mucous or salivary glad retention cyst and will resolve spontaneously
When you place a gloved finger inside the infant’s mouth with the finger pad up what are you assessing for?
Hard and soft palate continuity; strength and coordination of suck, and gag reflex
Epstein Pearls
Usually disappear by a few weeks of age.
Epithileal inclusion cells.
Bohns Nodules
Found on the gums
Histologically the same as epstien pearls
Natal Teeth
Usually found in lower incisor region after birth.
Immature caps of enamel and dentine with poor root formation and can be very mobile.
Rare among Caucasians but Common with Native American babies.
Why are natal teeth recommended to be removed?
May cause ulcerations of tongue and pain with feeding, and presumed risk of aspiration.
Requires dental consultation.
Excessive oral secrtions are abnormal in the newborn. What should the examiner consider?
Ruling out esophogeal atresia or poor swallowing from a nuerologic condition.
If there is concern for esophogeal patency what should the examiner do?
Pass a 10 Fr catheter down and perform xray to verify placement.
When assessing the neck how should you palpate?
Anteriorly, laterally, and posteriorly
What is the most common neck mass seen in infant’s?
Cystic hygroma
What causes cystic hygromas?
Development of sequestered lymph channel, which dilate into larger cysts.
How do cystic hygromas appear?
Soft, fluctuant, transilluminate well, usually seen laterally over clavicle
How are Cystic Hygromas treated?
Depending on size, may have to support feeding measures and airway compromise.
Small hygromas may regress spontaneoulsy but usually surgical resection is required.
What is a thryoglossal duct cyst?
A cyst found high on the neck.
What is a brachial cleft cyst?
Located on the sternocleidomastoid muscle
What is a brachial sinus
May communicate deeper with structures; and infection may necessitate surgical removal of the entire sinus tract.
Redundant neck skin or webbing of the neck is associated with what?
Downs syndrome, Turners syndrome, Noonans Syndrome
What are you examining when assessing clavicles?
Checking for fractures
