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Abnormal Head PositionAbnormal Head Position
Eric A. Lichtenstein, MD FAAPEric A. Lichtenstein, MD FAAP
Abnormal Head Position (AHP)Abnormal Head Position (AHP)
TiltTilt headhead
TurnTurn faceface
ChinChin up/downup/down
Ocular AHPOcular AHP
adaptive mechanismadaptive mechanism
neck control required neck control required
Ocular AHP: AdaptationOcular AHP: Adaptation
Strabismus Strabismus (avoid double)(avoid double)
Ptosis Ptosis (seek stereo)(seek stereo)
Nystagmus Nystagmus (improve acuity)(improve acuity)
Ocular AHPOcular AHP
Double vision Double vision (strabismus)(strabismus)
Stereo acuity Stereo acuity (ptosis)(ptosis)
Visual acuity Visual acuity (nystagmus)(nystagmus)
Not issues during sleep Not issues during sleep
AHP HxAHP Hx
Does AHP persist with sleep?Does AHP persist with sleep?Ocular: noOcular: no
How old when AHP began?How old when AHP began?Ocular: 3 to 4 monthsOcular: 3 to 4 months
Ocular AHPOcular AHP
Straighten the headStraighten the headStrabismus?Strabismus?
Ptosis?Ptosis?Nystagmus?Nystagmus?
AHP: StrabismusAHP: Strabismus
Avoid double visionAvoid double vision
Enhance depth perceptionEnhance depth perception
StrabismusStrabismus
ComitantComitantAngle Angle samesame in every gazein every gaze
AHP: no benefitAHP: no benefit
IncomitantIncomitantAngle Angle variesvaries with gazewith gaze
AHP: may benefitAHP: may benefit
Incomitant strabismusIncomitant strabismus
A/V PatternsA/V PatternsDuane SyndromeDuane Syndrome
Cranial Nerve PalsiesCranial Nerve PalsiesMiscellaneousMiscellaneous
Duane syndromeDuane syndrome
Synkinesis 3Synkinesis 3rdrd/6/6thth nervenerveCoCo--contraction contraction (medial/lateral recti)(medial/lateral recti)
CongenitalCongenitalHearing deficitsHearing deficits
Duane syndromeDuane syndrome
AADD--duction (looking in) duction (looking in) –– lids closelids close
Duane syndromeDuane syndrome
AABB--duction (looking out) duction (looking out) –– lids openlids open
Duane Syndrome?Duane Syndrome?
8 mo healthy 8 mo healthy ♂♂
Acute onset AHPAcute onset AHP
URI 1 week priorURI 1 week prior
Acute onsetAcute onset
Poor APoor ABB--duction duction
Lid height constantLid height constant
Duane SyndromeDuane Syndrome
4 months later4 months later 11 months later11 months later
PostPost--viral 6th Nerve Palsy: Observeviral 6th Nerve Palsy: Observe
66thth Nerve Palsy: When to ScanNerve Palsy: When to Scan
Not postNot post--viralviral
Not isolatedNot isolatedany other cranial nerveany other cranial nerve
any descending tract paresis/palsyany descending tract paresis/palsy
Motor or other developmental delayMotor or other developmental delay
44thth Nerve Nerve ““PalsyPalsy””Most common CN AHPMost common CN AHP
Abnormal rotation: Abnormal rotation: Lax SO tendonLax SO tendon
Not actually a palsyNot actually a palsy
2/3 of adults with 2/3 of adults with SOP are congenital SOP are congenital casescases
Neck and face Neck and face changeschanges
NystagmusNystagmus
Involuntary rhythmic oscillationInvoluntary rhythmic oscillation
Conjugate : same direction Conjugate : same direction
Dysconjugate: different directionsDysconjugate: different directions
NystagmusNystagmus
AmplitudeAmplitudeFrequencyFrequencyMagnitude = Amplitude x FrequencyMagnitude = Amplitude x Frequency
Null zone: where magnitude is Null zone: where magnitude is leastleast
NystagmusNystagmusCan be benignCan be benign
Can herald CNS massCan herald CNS mass
““SafeSafe”” -- horizontal in all directions of gazehorizontal in all directions of gazepresent present ““since birthsince birth””decreasesdecreases with near viewingwith near viewing** albinism** albinism
Congenital Motor NystagmusCongenital Motor Nystagmus
BenignBenign
““SafeSafe”” ---- horizontal in all directions of gazehorizontal in all directions of gazepresent present ““since birthsince birth””decreasesdecreases with near viewingwith near viewing
Null zone evident (AHP present)Null zone evident (AHP present)
Congenital Motor NystagmusCongenital Motor Nystagmus
BenignBenign
““SafeSafe”” ---- horizontal in all directions of gazehorizontal in all directions of gazepresent present ““since birthsince birth””decreasesdecreases with near viewingwith near viewing
Null zone evident (AHP present)Null zone evident (AHP present)
Null zoneNull zone
Nystagmus dampened by gazeNystagmus dampened by gaze
AHP utilized to look into null zoneAHP utilized to look into null zone
Can change early in lifeCan change early in life
Can be shifted (surgery)Can be shifted (surgery)