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Funny Shaped Heads Ronald L. Young II, MD. Funny shaped heads Etiologies Congenital deformities Congenital deformities Positional molding Positional.

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Presentation on theme: "Funny Shaped Heads Ronald L. Young II, MD. Funny shaped heads Etiologies Congenital deformities Congenital deformities Positional molding Positional."— Presentation transcript:

1 Funny Shaped Heads Ronald L. Young II, MD

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3 Funny shaped heads Etiologies Congenital deformities Congenital deformities Positional molding Positional molding Cephalohematomas Cephalohematomas Mass lesions Mass lesions

4 Molded Heads PlagiocephalyBrachycephalyScaphocephaly

5 Positional Plagiocephaly Occipital flattening Anterior displacement ear Bulge forehead Bulge malar eminence Parallelogram Local bald spot

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7 Positional Plagiocephaly Associated with “torticollis” Short sternocleidomastoid on flat side Not stretched out Not stretched out Decreased rotation away from flat side Uterine constraint

8 Positional brachycephaly Symmetric flat occiput Increased bi-parietal diameter No ridging Focal bald spot Severe cases have ears pointing down

9 Positional brachycephaly Deep sleepers Don’t move after falling asleep Don’t move after falling asleep Don’t sleep in bed Infant seat Infant seat Bouncy seat Bouncy seatHypotonia Cause not effect Cause not effect

10 Positional Scaphocephaly “Premie head” Common in severe premies Can evolve into craniostenosis VP Shunt VP Shunt

11 Pathology Soft skull Weight of brain able to flatten skull Rapidly growing skull Self sustaining Flat tire Flat tire

12 Time Course Flat spot noticeable 1 m/o Deformity peaks 4 m/o (Corrected) Head control Head control Primary deformity Flat spot Flat spot Secondary deformity Compensatory bulge Compensatory bulge

13 Time Course Improvement of the flat spot 6 m/o Posterior bulge Posterior bulge Dent in inion 6 m/o Bulge takes 12-16 months 2 y/o Brain molds from inside Brain molds from inside

14 Time Course Ear asymmetry 3 y/o Not cosmetic problem Not cosmetic problem Rare residual deformity

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16 Why So Long? Head Growth

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18 Treatment Position Therapy Keep off the flat spot Sleep <4 m/o Wedges and blankets <4 m/o Wedges and blankets Roll on side >4 m/oFetal position >4 m/oFetal position Let baby fall asleep in usual position Let baby fall asleep in usual position Then rotate onto side in fetal position Start at naps Start at naps

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20 Treatment Position Therapy Sit up in swing Get out of bouncy seat and infant seat Exer-saucerWalker “Tummy Time”

21 Treatment Molding Helmet Act like dental braces Slowly push in secondary deformity Keep off the primary deformity

22 Treatment Molding Helmet Patients with helmets look better faster Need to be worn to work Shoot for 23 hours / day Shoot for 23 hours / day Need to be custom fit Earlier the better Won’t work as well after 12 mo

23 Treatment Molding Helmet Cost Cranialtech$3000 Cranialtech$3000 Advanced Orthopro$1400 Advanced Orthopro$1400Complications Compliance Compliance Skin breakdown Skin breakdown

24 Treatment Molding Helmet My indications Borderline parents Borderline parents Can’t get concept of keeping off flat spot Hypotonic children Hypotonic children Won’t have head control by 4 months Hydrocephalus post shunt Hydrocephalus post shunt Will not have brain growth to mold skull Significant facial bulge Significant facial bulge Just not getting better Just not getting better

25 Craniosynostosis

26 What is it? Premature fusion of the cranial sutures Sutures allow progressive enlargement of the skull with brain growth Normal sutural fusion is complete at 6 to 8 years of age Premature fusion produces progressive skull deformity

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29 Epidemiology Occurs in 1 in 2100 children Primary non-syndromic is most common Lambdoid synostosis is very rare Multiple sutures involved in 8% of non- syndromic cases

30 Calvarial Development Intramembranous ossification Margins of calvarial bones form osteogenic front Sutures form at sites of near contact New bone is laid down by osteoblasts in spicules at the sutural margins Overall bone growth is driven by the expanding brain

31 Calvarial Development

32 Pathobiology Metabolic disorders Rickets Rickets Hyerthyroidism Hyerthyroidism Mucopolysaccharido ses Hurler’s, Morquio’s Hurler’s, Morquio’s Hematologic disorders Thalassemias, sickle cell anemia, polycythemia vera Thalassemias, sickle cell anemia, polycythemia vera Teratogens Valproic acid, aminopterin, retinoic acid Valproic acid, aminopterin, retinoic acidMalformation Microcephaly Microcephaly Encephalocele Encephalocele shunted hydrocephalus shunted hydrocephalus holoprosencephaly holoprosencephaly Known causes of craniosynostosis

33 Pathobiology Syndromic Crouzon Crouzon Apert’s Apert’s Pfeiffer Pfeiffer Jackson-Weiss Jackson-Weiss

34 Pathobiology <10% inherited or syndromic 90% spontaneous Uterine constraint Uterine constraint Early drop into cervical canal Multiple births Severe back pain last month of pregnancy

35 Pathobiology Premature closure of calvarial sutures also affects the skull base Coronal and metopic Effect extends to nasoethmoid complex, orbital roofs, and supraorbital ridges Effect extends to nasoethmoid complex, orbital roofs, and supraorbital ridges

36 Diagnosis Characteristic skull shape Lack of movement at suture Palpable ridging of fused suture CT scan Fusion, sclerosis, skull base deformities Fusion, sclerosis, skull base deformities

37 Metopic

38 Metopic

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40 Unicoronal

41 Bicoronal

42 Sagittal

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44 Lamdoid

45 Cloverleaf deformity

46 The case for surgery Aesthetic and functional Elevated ICP in 14% of single and 47% of children with multiple sutural synostosis Uncorrected children often socially isolated and stigmatized Low risk with modern craniofacial surgery

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48 Surgery

49 Surgery

50 Complications Blood loss Infection CSF leak Post surgical trauma Poor cosmetic result Persistent cranial defects

51 Results

52 Results

53 Results

54 ?

55 Thank You!


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