Head

Question 1

Physical Assessment of the Head (6)

Answer 1

1. Look for torticollis (inability to turn the head in both directions)
2. Examine the head from above and side
3. Examine the entire head using fingertips
4. Feel for ridge over sutures
5. Face
   - - Forehead and upper orbit
   - - Orbitonasal zygomatic area
   - - Maxillomandibular area
   - - Posterior cranial vault
6. Examine the extremities and back of child with deformation of head since congenital dislocation, scoliosis and deformed feet are more common. **

Question 2

When performing the physical assessment…(3)

Answer 2

1. When you examine head, you want to look above, from both sides, at general shape, and at the eyes
2. Look at head from face on
3. Look at extremities, because deformation of head could indicate problems with the spine

Question 3

LOOK AT YOUR SLIDE OF THE SUTURES YOU NEED TO MEMORIZE THEM! (5)

Answer 3

1. Metopic: frontal suture in the middle (vertical)
2. Coronal: frontal horizontal suture
3. Saggital suture down the middle of the head
4. Lamboidal suture is in the back
5. Squamosal: suture above the ears

Question 4

Looking at head circumference

Answer 4

Check where child (

Question 5

When do you measure the head?

Answer 5

Measure the head at 2,4,6,9,12,15,18 months,2.5,3 year old well child visits

Question 6

Transilluminating the skull

Answer 6

can tell you how much brain is there; if there is a lot of transilluminating then there is low brain volume
*Arteriovenous malformation of brain can be indicated by bruit

Question 7

Macrocephaly Head Assessment (7)

Answer 7

1. Serial head measures
2. Measure parents head
3. Developmental history
4. Transilluminate skull
5. Look for skeletal dysplasia !
6. Listen for bruit (can indicate arteriovenous malformation)
7. Look for sunset eyes
8. Signs of neurocutaneous disorder

Question 8

Sunset eyes

Answer 8

when you can see sclera above the iris; can see top of the sclera; consider thyroid disease or hydrocephalus

Question 9

Cafe au lait spots

Answer 9

Cafe au lait spots or flat round macules may indicate neurofibromitosis

Question 10

Causes of microcephaly (6)

Answer 10

1. Genetic defect
2. Karyotype or axon sequencing can tell u
3. Intrauterine infections
4. Antenatal radiation
5. Exposure to drugs and chemicals
   * Certain anti-epileptics
6. Perinatal insult (can be due to in utero virus)

Question 11

Scaphocephaly or dolichocephaly

Answer 11

Scaphocephaly: long, narrow head in an infant
Dolichocephaly: longer head than normal

Can be caused by positional problems in the premature infant

• Saggital Craniosynostosis
• If saggital suture closes too soon, it causes the head to grow longwise instead of outward/circular (will be a long-narrow head)

Question 12

Plagiocephaly

Answer 12

Common with back head sleep position, torticollis;

Due to position, not premature closure; due to back-to-back sleep campaign

Question 13

Craniosynostosis (5)

Answer 13

1. Rare condition in which the skull sutures close and the bony plates of the skull become fused too early in life.
2. Develops while the fetus is still in the mother’s womb
   
   • • 1 in every 2,500 births
3. Sagittal suture closes prematurely
4. Can occur as a part of a larger pattern of abnormalities
5. Two main categories:
   - - Simple or isolated craniosynostosis
   - - Complex or syndromal craniosynostosis

Question 14

Looking for craniosynostosis

Answer 14

Palpate over all sutures and feel for any overriding bones; will be normal right after birth but then they should open up

Craniosynostosis: not necessarily genetic; normal variation that occurs to cause narrow head
*But complex type could be due to one of the sutures being completely shut leading to differences in head shape

Question 15

Scaphocephaly (4)

Answer 15

1. No growth perpendicular to sagittal suture; can cause promminent occiput that is long and narrow
2. Bitemporal narrowing
3. Cranial elongation in anterior-posterior direction
4. Characteristic: Frontal bossing and prominent occiput

Need to know what an open vs. closed suture looks like on X-ray; When a suture is open you can see a line through it

Question 16

Brachycephaly (4)

Answer 16

1. Bilateral coronal or lambdoidal (11%)
   * Occurs when coronal or lamboidal suture closes prematurely; when both close you get “HIGH-HAT” apperance
2. Broad skull with a short base and a recessed
   lower forehead.
3. Caused by premature closure of the coronal
   suture on both sides of the head
4. Associated with:
   - - Apert syndrome
   - - Crouzon syndrome
   - - Pfeiffer syndrome

Question 17

Crouzon’s Syndrome (4)

Answer 17

1. Craniosynostosis most often of the coronal and
   lambdoid, and occasionally sagittal sutures
2. Underdeveloped midface with receded
   cheekbones or exophthalmos (bulging eyes)
3. Ocular proptosis which is a prominence of the
   eyes due to very shallow orbits.
   *Inward turning iris and shallow eyes
   *Very croptotic eyes; shallow orbit causing eyes to come out
   *Can see high-hat
4. Esotropia and/or wide-set eyes.

Question 18

Apert syndrome (5)

Answer 18

1. Very high brachycephalic head
2. Severe syndactyly affecting all limbs.
3. Syndactyly involves bony fusion of fingers and toes
4. Apert is the second most common craniofacial syndrome after Crouzon.
5. Can see the brachiocephaly; high forehead, low set ears

Question 19

Metopic Craniosynostosis

Answer 19

Causes ocular problems/fusion problems
*Doesn’t require immediate surgery

• See pointed frontal
• Palpation can indicate the overriding sutures

Question 20

Oxycephaly

Answer 20

Closure of all sutures except squamosal; requires urgent surgery to open all the sutures

*Can cause dysmorphic features

Question 21

Positional Plagiocephaly (5)

Answer 21

1. Face will be pushed forward on the affected side
2. Frontal Bossing due pressure on the occiput
3. The ear on the affected side will be forward in comparison to the unaffected side
4. A parallelogram will be formed.
5. OCCURS BECAUSE OF A LACK OF TURNING; not a problem with sutures but a problem with positioning

Question 22

Lambdoidal Craniosynostosis (3)

Answer 22

1. 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.
2. Sincethereisgrowth restriction on the affected side, there is overgrowth everywhere else
3. Atrapezoid results (leads to a trapezoid shape)
   * Face is assymetrical; so one side of the face goes further out than the other

Question 23

Characteristics of Crouzon’s (3)

Answer 23

1. Multiple craniosynostoses
2. Bulging or proptotic eyes
3. Small eyes

Question 24

Waardenburg syndrome (5)

Answer 24

1. White forelock (white strip of hair) and beak nose
2. Normal IQs
3. Eyebrows are slightly bushy
4. Triangular face, slightly pointed chin
5. With waardenburg, it’s genetic and you develop hearing loss later in life; the amount of hearing loss varies from person to person

Question 25

Differentiating Alopecia Areata from Tinea Capitis

Answer 25

Key points: 1. Age 2. Black dot sign 3. Race 4. Pattern of hair loss With tinea capitis, hallmark sign is tiny mm short ends of (short black dots) where the hair loss is and the pattern of hair loss is circular

Question 26

Alopecia Areata (distribution, onset, appearance, degree of shedding, age of onset, results of pull test, other)

Answer 26

Distribution: Usually patchy, can be multi-focal Onset: Abrupt; waxes and wanes Appearance: Thin with abrupt bare patches, exclamation point hairs Degree of shedding: Prominent Age of onset: Any age, but usually before 20 Results of pull test: Positive Other: Personal or family history of autoimmune disease; needs TSH test

Question 27

Tinea Capitis (distribution, onset, appearance, degree of shedding, age of onset, results of pull test, other)

Answer 27

Distribution: Specific area, focal, or multi-focal Onset: Gradual or abrupt *Usually comes out slowly over time Appearance: None to some inflammation, scaling *Allergic boggy inflammation on scalp Degree of shedding: Prominent Age of onset: Common in any childhood, any age Results of pull test: Positive Other: Contact with animal with dermatophytes

Question 28

Midface Hypoplasia

Answer 28

1. Associated with sleep apnea and stridor * Take a very detailed history of sleep apnea 2. Dental problems 3. May have hearing problems

Question 29

Micrognathia (5)

Answer 29

1. Too small of chin and forward advancement of jaw 2. The mandible has not grown as much as it should resulting in a small mandible and chin. 3. Advancement of the mandible and advancement of the chin surgically. 4. The correction is done via the intraoral route without any incisions on the face 5. Preceded by orthodontic treatment to align the teeth prior to proper surgical treatment.

Question 30

Prognathic Mandible (3)

Answer 30

1. When the lower jaw is too prominent 2. Occurs with congenital overgrowth of the lower jaw 3. Certain pathologic such as gigantism due to pituitary overgrowth and other tumors or congenital deformities

Question 31

Temporomandibular Joint (3)

Answer 31

1. Place the tips of your index fingers directly in front of the tragus of each ear 2. Ask the patient to open and close their mouth. 3. Record any decreased range of motion, tenderness, or swelling

Question 32

Presence of Vascular Marks or Massess

Answer 32

1. Masses - Dermoid cyst - Bone cysts - Loss of hair - Scars 2. Presence of infection - Palpate to identify any areas of tenderness of deformity Always look for infection!

Question 33

Sturge Weber Syndrome (4)

Answer 33

1. Look for non elevated purple venous malformation in the distribution of trigeminal nerve involves ophthalmic division * Well demarcated area of redness 2. High incidence of mental retardation 3. Ocular complications (glaucoma) on the affected side * Needs glaucoma drops for remainder of life 4. Can cause deformation in brain leading to seizures

Question 34

Salivary Gland Parotid

Answer 34

Submandibular and sublingual glands How to Assess: The Salivary Gland Parotid: Palpate the gland and look at the angle of the jaw * Under tongue there are salivary glands; when assessing the salivary glands, it’s important to pay attention to the angle of the jaw * Enlargement of salivary glands can lead to obscured angle of jaw

Question 35

Parotid Duct Orifices (3)

Answer 35

1. On the buccal mucosa opposite the upper second molar 2. Massage of the gland should express clear fluid. * Massaging duct glands should release clear fluid, not pus * As you massage, they secrete onto the floor of the mouth 3. The submandibular and sublingual glands empty into the floor of the mouth.

Question 36

Differential DIagnosis for Parotiditis: Wind Parotiditis

Answer 36

Air is forced into parotid duct with glandular swelling from children learning to play a wind instrument or from blowing up balloons

Question 37

Other differential Diagnoses for Parotiditis (10)

Answer 37

1. Viral causes include mumps, parainfluenza type I and 3, HIV, and other such as CMV, coxsackie 2. Bacterial infections - - Staphylococcus aureus - - Streptococcus species - - Can have a tender and red gland with significant systemic symptoms 3. Recurrent parotiditis is associated with pain, fever 4. Abscess of parotid * Parotid stone can be mistaken for worms 5. Much rarer: Cat scratch, TB and other such as tularemia as part of uveoparotid syndrome 6. Metabolic causes - - Will be slow, progressive, painless and lacking inflammation 7. Starvation/Anorexia 8. Cushing Syndrome 9. Obstructive enlargement (seen with stones) 10. Autoimmune problems; lupus with recurrent swelling or Sjorgen syndrome