An Intro to

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An Intro to Abnormal Head Shapes

• An introduction to abnormal head shapes

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Craniosynostosis

• Early suture closure associated with a small head
  circumference and rigid sutures

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Primary Craniosynostosis

• 1 or more sutures fuse prematurely
• Growth is restricted perpendicular to the suture
• If multiple sutures fuse while the brain is still
  increasing in size, intracranial pressure can
  increase

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Secondary Craniosynostosis

• More frequent than primary craniosynostosis
• Results from early fusion of sutures due to
  primary failure of brain growth
• results in microcephaly
• Intracranial pressure usually is normal
• Surgery seldom is needed

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Head Shapes
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Scaphocephaly

• Premature fusion of the sagittal suture
• MC craniosynostosis (gt 50)
• Head is elongated in the A-P
  diameter and shortened in the
  biparietal diameter
• Ridging of the sagittal suture is palpable

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Brachycephaly

• Premature fusion of both coronal sutures
• Increased biparietal diameter, shorter A-P
  diameter

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Trigonocephaly

• Premature fusion of the metopic suture
• Results in pointed forehead
• usually mild and requires no surgical
  intervention
• MILD--------------------------------------------SE
  VERE

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Posterior Plagiocephaly

• 2 predominant causes of posterior plagiocephaly
• craniosynostosis of the lambdoid suture (lt2)
• positional molding (vast majority)
• Craniosynostosis
• trapezoid shaped
• frontal bossing is observed contralateral
  to the flattening

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VS.Positional Head Deformity
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If plagiocephaly is present at birth

• Differentials include
• In-utero or intrapartum molding
• uterine constraint
• multiple birth infants
• birth injury associated with forceps or
  vacuum-assisted delivery
• premature birth
• Craniosynostosis (lambdoid suture)

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If plagiocephaly develops later

• result of static supine positioning
• AAP, 2003
• Torticollis
• Back to Sleep campaign
• Since 1992 there has been a significant increase
  in the diagnoisis of plagiocephaly
• one center reported a six-fold increase
  (1992-1994)
• Subluxation

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Epidemiology

• 1992 1 per 300 healthy infants
• 1999 1 per 60 healthy infants

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Examination

• Palpate lambdoidal suture
• Palpable ridge suggests synostosis
• Check ear position
• Ear on flattened side more posterior suggests
  synostosis
• Ear on flattened side more anterior suggests PHD
• Assess facial symmetry
• Forehead prodruding on the side of flattening
  suggests PHD

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• Positional head deformity
• ear migrates forward
• forehead protrudes on the side of occipital
  flattening

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• Eyes may appear to have unequal positioning

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Examination

• Observe unilateral bald spot
• Unilateral bald spot suggests PHD
• Inspect by arial view
• Parallelogram shape suggests PHD

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• Positional Head Deformity (left) parallelogram
  shape
• Synostosis of lambdoid (right) forehead does
  not protrude

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Skull Radiographs and CT?

• Useful in cases with atypical skull pattern or
  moderate-severe skull deformity
• suspecting craniosynostosis

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Differential Diagnosis is Critical!

• Craniosynostosis
• Palpable ridge
• Ear on flat side more posterior
• Forehead does not protrude
• No bald spot (no sign of external pressure)

• Positional Head Deformity

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Management of PHD

• Preventive counseling for parents
• Mechanical Adjustments
• Exercises
• Skull modling helmets
• option for patients with severe deformity or
  skull shape that is refractory to therapeutic
  physical adjustments and position changes.
• AAP (2003)
• Surgery

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• Chiropractic Adjustments!

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Preventive Counseling

• Parents should be counseled during the newborn
  period (2-4 weeks)
• Alternate supine sleep positions (i.e. L R
  occ.)
• When awake and being observed, the infant should
  spend time in the prone position
• Minimal time in car seats (when not a passenger
  in a vehicle) or other seating that maintains
  supine positioning

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Mechanical Adjustments

• Position the infant so that the rounded side of
  the head is placed dependent against the mattress
• Change the position of the crib in the room
• require the child to look away from the flattened
  side to see the parents and others in his or her
  room

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Exercises

• Supervised tummy time on firm surfaces when the
  infant is awake and being observed
• If torticollis is present, parents should be
  taught specific neck motion exercises
• head rotation and lateral bend
• Done at each diaper change
• Hold 10 seconds 3 repetitions

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• Most will improve within 2-3 months
• If parents follow these guidelines!

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Referral

• If there is progression or lack of improvement
  of the skull deformity after a trial of
  mechanical adjustments, then referral to a
  pediatric neurosurgeon, a general neurosurgeon
  with expertise in pediatrics, or a craniofacial
  surgeon or craniofacial anomalies team should be
  considered.
• (AAP, 2003)
• correct diagnosis?
• subsequent management
• molding helmets or surgery

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Skull-Molding Helmets

• Research opinions are mixed
• Best results 4-12 months of age