Head and Neck

Examination of the head should include visual inspection, palpation, auscultation (for bruits over the temporal arteries and anterior fontanelle), assessment of the shape and size relative to the rest of the body and face, distribution and character of the hair and underlying scalp, and measurement of head circumference. The hair is inspected for color, texture, distribution and directional patterns. The shape of the cranial vault reflects interaction of internal (anatomy, volume, pressure) and external (intra- and extrauterine molding, suture mobility) forces. The mode of delivery will affect the shape of the head (e.g., vaginal delivery with vertex presentation leads to a narrowed biparietal diameter and a maximal occipitomental dimension; breech presentation may accentuate the occipitofrontal dimension with parietal flattening and frontal prominence). Normal molding resolves within a few weeks, but other aberrations progress.

Normal variations in contour, size, relationships, and range of motion of the newborn neck must be distinguished from congenital anomalies and traumatic lesions. The neck should be examined passively for rotation, lateral flexion, anterior flexion, and extension. Rotation of 80° and lateral flexion of 40° should be present and symmetric to both sides. Extension and flexion are difficult to measure, but in flexion the chin should touch or nearly touch the chest wall and extension should be 45° from neutral. When rotation or lateral flexion is asymmetrical or when motion is limited, radiographs of the neck should be obtained. The neck should be extended to look for clefts and cysts. The isthmus of a normal thyroid is just palpable in the sternal notch on neck extension. Other congenital neck masses include cystic hygroma, lymphangioma, and cervical teratoma. The earlier that appropriate treatment is started, the more likely that correction can occur.

Craniotabes Radiography

Figure 1.2. Lateral radiograph of a normal term newborn skull. Note the poor mineralization of the bones with separation of sutures. In the lateral view, mineralization of the lower teeth correlates well with gestational age. Mineralization of only the incisors indicates a gestational age of less than 33 weeks. Mineralization of the incisors and the first molars correlates with a gestational age of 33 to 37 weeks. Mineralization of the second molar in addition to the above correlates with less than 37 weeks gestation.

Figure 1.1. Anteroposterior radiograph of the normal newborn skull. Note the fontanelle and suture lines.

Figure 1.2. Lateral radiograph of a normal term newborn skull. Note the poor mineralization of the bones with separation of sutures. In the lateral view, mineralization of the lower teeth correlates well with gestational age. Mineralization of only the incisors indicates a gestational age of less than 33 weeks. Mineralization of the incisors and the first molars correlates with a gestational age of 33 to 37 weeks. Mineralization of the second molar in addition to the above correlates with less than 37 weeks gestation.

Craniotabes Soft Skull

Figure 1.3. Lateral radiograph of the skull showing the presence of an anterior fontanelle bone. This infant's head is somewhat elongated. Fontanelle bones are more common over the posterior fontanelle. There are no clinical signs and as the skull mineralizes these bones become confluent with the rest of the skull. The bone may be palpable in the fontanelle.

What The Third Fontanelle

Figure 1.4. Anteroposterior radiograph of the same infant as in Figure 1.3, showing the anterior fontanelle bone. The third fontanelle is a widening of the sagittal suture near the junction of its middle and posterior thirds. It represents slowed growth of the plates of the parietal bone and may be distinguished from the posterior fontanelle by its position and round or oval appearance.

Figure 1.4. Anteroposterior radiograph of the same infant as in Figure 1.3, showing the anterior fontanelle bone. The third fontanelle is a widening of the sagittal suture near the junction of its middle and posterior thirds. It represents slowed growth of the plates of the parietal bone and may be distinguished from the posterior fontanelle by its position and round or oval appearance.

Figure 1.6. The clinical appearance of congenital parietal foramina in an otherwise normal neonate. Note that the infant is lying on his face and the depressions over the parietal area reflect the defects. These are rounded defects in the parietal bone. They are usually bilateral and vary in size from 1 mm to 3 cm. They are usually asymptomatic but may cause concern because of bulging or pulsation of the overlying scalp.

Cephalhematoma
Homo FloresiensisNormal Baby Skull Radiograph
Figure 1.7. Radiograph of the skull of the same infant as in Figure 1.6. Note the posterior parietal foramina and poor mineralization of the skull with a large metopic suture.

Figure 1.8. Congenital parietal foramina are often familial, as noted in this radiograph of the skull of the mother of the same infant.

Linear Skull Fracture
Figure 1.9. A radiograph of a linear skull fracture over the parietal bone. This is not common in the neonate but may occasionally be associated with a cephalhematoma. It can also occur as a result of trauma.

1.10

Figure 1.10. Lateral radiograph of the skull of an infant with lacunar skull (luckenschadel), which is a result of defective calcification of the skull bones. Note the characteristic honeycomb skull appearance. This malformation is commonly associated with neural tube defects (encephalocele and meningocele) and is characterized by sharply defined depressions which are usually readily palpable and situated in the frontal and parietal areas.

Luckenschadel Skull

Figure 1.11. Frontal radiograph of the skull of the same infant with luckenschadel. Compare luckenschadel with craniotabes which consists of localized areas of softening in one or several bones of the vault of the skull. The involved bones feel like parchment and are easily indented when pressed with the fingertip. When the pressure is removed, the soft bone resumes its former contour in much the same way as an indented ping pong ball recovers its shape. Craniotabes is more common in term infants than in premature infants. It is commonly found in normal infants, hydrocephalic infants, and in infants with osteogenesis imperfecta.

1.11

Figure 1.11. Frontal radiograph of the skull of the same infant with luckenschadel. Compare luckenschadel with craniotabes which consists of localized areas of softening in one or several bones of the vault of the skull. The involved bones feel like parchment and are easily indented when pressed with the fingertip. When the pressure is removed, the soft bone resumes its former contour in much the same way as an indented ping pong ball recovers its shape. Craniotabes is more common in term infants than in premature infants. It is commonly found in normal infants, hydrocephalic infants, and in infants with osteogenesis imperfecta.

Figure 1.12. Lateral skull radiograph of luckenschadel in anodier infant with a lumbar meningocele, imperforate anus, and rectovaginal fistula.

Figure 1.12. Lateral skull radiograph of luckenschadel in anodier infant with a lumbar meningocele, imperforate anus, and rectovaginal fistula.

Hydrocephalic Skull
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Responses

  • WALTER YANEZ
    What is the third fontanelle?
    8 years ago
  • Yasmin
    What can cause encephalocele?
    7 years ago

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