Posterior Deformational Plagiocephaly Research Articles

Distinguishing Craniomorphometric Characteristics of Unilateral Lambdoid Craniosynostosis.

Unilateral lambdoid synostosis (ULS) represents the rarest form of single suture nonsyndromic craniosynostosis. Differentiating between posterior deformational plagiocephaly (DP) and ULS has been difficult due to overlapping clinical findings. Past analyses have been limited by sample size. This study was undertaken to clarify anatomical features of ULS. A multiinstitution study was undertaken, analyzing CT imaging from patients with documented ULS to determine clinical and pathological characteristics. Similar analyses were performed on DP patients to differentiate the 2 conditions. Twenty-seven ULS patient scans and 10 DP scans were included. For ULS patients mean age was 6.6 months, majority male (75%), and majority left-sided ULS (71%). The synostosed side ear was anteriorly displaced in 100% of ULS patients, mean difference of 9.6° (P < 0.001), and inferiorly in 96.3% of patients, mean difference of 4.4 mm, relative to the nonsynostosed side. The posterior fossa deflection (PFD) was deviated 5.9° toward the synostosed side relative to the anterior midline. In DP, there was no significant difference between sides in EAC measurements. The PFD and EAC displacements were significantly smaller in DP relative to ULS (P < 0.001 for each). An ipsilateral mastoid bulge was found in 100% of ULS and 0% of DP on CT imaging. Contrary to some previously published findings, the ear is more anteriorly displaced ipsilateral to the fused lambdoid suture in 100% of ULS patients. Ear position alone is not a reliable indicator to differentiate between DP and ULS. A mastoid bulge is a more reliable indicator of ULS.

Periocular Asymmetry in Infants with Deformational Posterior Plagiocephaly

ABSTRACTPurpose: To analyze the clinical significance of the periorbital features associated with the facial asymmetry that is common in deformational posterior plagiocephaly (DPP).Patients and methods: We identified 32 patients with DPP, photographed their faces and tops of their head, and performed a complete eye examination. Four examiners analyzed the patient’s periorbital features on the photographs.Results: Median age was 6.5 months (range 3–12 months). Pseudoptosis was identified in 30 patients and pseudo-brow ptosis in 19. Pseudoptosis was marked in 17 patients. Five patients were misdiagnosed with congenital blepharoptosis and received regular follow-ups for amblyopia checks until the diagnosis of pseudoptosis was established. All patients had normal levator function and symmetric eyelid crease. One patient with pseudoptosis and physiologic anisocoria was diagnosed with pseudo-Horner syndrome after a negative 10% cocaine test. None of the patients developed meridional or occlusion amblyopia.Conclusion: DPP is the most frequent form of skull deformation in infants. Its main features are occipital flatness and facial asymmetry. Infants with DPP may present with pseudoptosis and pseudo-brow ptosis on the contralateral side of the occipital flatness. The pseudoptosis in DPP is non-amblyogenic, therefore, ophthalmologic intervention and regular follow-ups are not necessary unless other abnormalities co-exist.

Evidence-Based Care of the Child With Deformational Plagiocephaly, Part I: Assessment and Diagnosis

Non-synostotic deformational plagiocephaly (DP) is head asymmetry that results from external forces that mold the skull in the first year of life. Primary care providers are most likely to encounter DP when infants present for well-child care, and for this reason it is important that providers be competent in assessing, diagnosing, and participating in the prevention and management of DP. The purpose of this two-part series on DP is to present an overview of assessment, diagnosis, and evidence-based management of DP for health care providers. In Part I we provide a brief background of DP and associated problems with torticollis and infant development, and we present strategies for visual and anthropometric assessment of the infant with suspected DP. We also provide tools for differentiating DP from craniosynostosis and for classifying the type and severity of lateral and posterior DP. Part II (to be published in a future issue of the Journal of Pediatric Health Care) provides a synthesis of current evidence and a clinical decision tool for evidence-based management of DP.

Deficient language acquisition in children with single suture craniosynostosis and deformational posterior plagiocephaly

This study examined early language acquisition in children with single suture craniosynostosis (SSC) and in children with deformational posterior plagiocephaly. Our purpose was to determine whether infants with SSC have normal language acquisition at the age of 3 years, and whether infants with deformational posterior plagiocephaly demonstrate parallel development when compared with children with SSC. The study population includes 61 infants. Twenty of them had synostosis of the sagittal suture, 12 synostosis of other suture and 29 deformational posterior plagiocephaly. Forty-nine of them were operated on a mean age of 10.6 months, and 12 were non-operated children with deformational posterior plagiocephaly. Language skills of participants were prospectively evaluated at the mean age of 3 years 4 months. About one half of the subjects (49%) had normal linguistic development, 30% had slight developmental problems and 21% had severe disorders in speech-language-related skills. These figures showed the prevalence of severe language disorders to be three times higher in our study population when compared with the general population. Children with sagittal synostosis managed better in all language skills compared with other types of SSC. Defective language development was found in deformational posterior plagiocephaly, both operated and non-operated. We found a noticeable developmental risk for specific language impairment in children with nonsyndromic SSC, and that the deviant language development is observable already in early infancy. Contrary to previous beliefs, the developmental risk for defective language development in deformational posterior plagiocephaly was found in both operated and non-operated subjects.

Posterior deformational plagiocephaly properly explains the cranial asymmetries in LB1: A reply to Eckhardt and Henneberg

Posterior deformational plagiocephaly properly explains the cranial asymmetries in LB1: A reply to Eckhardt and Henneberg

Radiological Reasoning: A Child With Posterior Plagiocephaly

Received September 11, 2009; accepted after revision March 14, 2009. 1Both authors: Department of Radiology, Children’s National Medical Center, 111 Michigan Ave., Washington, DC 20010. Address correspondence to N. Kadom (nkadom@cnmc.org). AJR 2010;194:WS5–WS9 0361–803X/10/1943–WS5 © American Roentgen Ray Society OBJECTIVE A 10-month-old girl presented with an abnormal left posterior head shape and was referred for head CT to evaluate for the possibility of lambdoid craniosynostosis. At CT, a diagnosis of deformational plagiocephaly was made. An understanding of CT criteria to differentiate posterior deformational plagiocephaly from abnormal head shape caused by lambdoid craniosynostosis is necessary to help make the correct diagnosis.

PLAGIOCEPHALY, BRACHYCEPHALY AND CRANIAL ORTHOTIC DEVICES: MISSHAPEN HEADS AND HELMETS

The apparent prevalence of plagiocephaly has increased in recent years as indicated by referrals to paediatricians, neurosurgeons and craniofacial surgeons for advice and management.1 For the purposes of this article,...

Long-Term Treatment Effectiveness of Molding Helmet Therapy in the Correction of Posterior Deformational Plagiocephaly: A Five-Year Follow-Up

To evaluate the long-term effectiveness of helmet therapy in the correction of deformational plagiocephaly and to assess the early occlusal abnormalities seen in these patients. A prospective study with blinded measurements. Twenty-eight patients with deformational plagiocephaly who were treated with molding helmet therapy with at least 5 years of follow-up. The average length of molding helmet treatment was 6.2 months. At the time of this follow-up evaluation, the mean interval since completing the molding helmet therapy was 5.6 years. Anthropometric measurements of cranial asymmetry included cranial vault asymmetry (CVA), orbitotragial depth asymmetry (OTDA), and cranial base asymmetry (CBA). A dental examination was also performed. At the completion of therapy, the most improvement was seen in the measurement of CBA, followed by CVA and OTDA. However, in evaluating the long-term stability of molding treatment, OTDA tended to continue improving after the initial treatment, while CBA and CVA appeared to regress, although none of the changes reached statistically significant levels. In dental measurements, all the dental midline and chin deviations were toward the unaffected side with respect to occipital deformation. This study demonstrated that helmet remodeling with the dynamic orthotic cranioplasty band is effective in the correction of cranial asymmetry, with some nonstatistically significant changes in long-term cranial vault symmetry. Dental observations indicated the possibility of occlusal abnormalities that may affect dental, especially orthodontic, diagnosis and treatment planning.

Torticollis, facial asymmetry and plagiocephaly in normal newborns

Objective: To evaluate the incidence and characteristics of torticollis, plagiocephaly and facial asymmetry in normal newborn infants. Design: 102 healthy newborn infants were examined prospectively during their birth hospitalisation for...

Comparison of a Modifiable Cranial Cup versus Repositioning and Cervical Stretching for the Early Correction of Deformational Posterior Plagiocephaly

Deformational occipital flattening is the most common cause of abnormal head shape. Current treatment calls for repositioning and cervical stretching in infants younger than 5 months. The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly. This nonrandomized, prospective clinical trial used historical controls. The treatment and control groups consisted of infants, younger than 4 months, referred for deformational posterior plagiocephaly. The control children were managed by repositioning and cervical stretching exercises. An adjustable concave cranial cup was used in the treated group. Infants were examined at the initial and final visits by a single examiner. Calvarial asymmetry was measured using a large cranial caliper. Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees. There were no statistically significant differences between the control (n = 23) and treatment groups (n = 24) with respect to gestational age at birth, age at initial visit, initial head rotational asymmetry, initial transcranial difference, final head rotational asymmetry, and age at final evaluation. Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group. The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group, and from 9.0 to 8.0 mm in the control group (p = 0.000). The cranial cup, a modifiable concave resting surface, is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly.

MDCT Diagnosis of the Child with Posterior Plagiocephaly

In this article, we review the normal anatomy and development of the posterior skull base and describe distinguishing imaging features of the two most common causes of posterior plagiocephaly: posterior deformational plagiocephaly and unilateral lambdoid synostosis. We also describe three unusual cases of posterior plagiocephaly, including asymmetric premature fusion of the anterior and posterior intraoccipital synchondroses, with diagnoses enabled by volume-reformatted MDCT. Three-dimensional reformatted MDCT enables accurate diagnosis of common and rare causes of posterior plagiocephaly in children.

Visual Field Defects in Deformational Posterior Plagiocephaly

We sought to determine whether visual field abnormalities occur in infants with deformational posterior plagiocephaly and to assess whether there is a relationship between the severity and laterality of visual field abnormalities with the severity and laterality of skull deformity. A retrospective chart review was performed on 40 consecutive infants with deformational posterior plagiocephaly. Each was tested with standardized binocular arc perimetry in the horizontal plane. Sixteen patients also had 3-dimensional computed tomography of the skull. Hemifield asymmetry of >/=20 degrees and/or a decrease in hemifield values by >/=20 degrees from established normal patients was considered abnormal. Visual field data from study patients was plotted against previously published normative data. Graphs comparing visual field defects and laterality to cranial asymmetry also were generated. Thirty-five percent of infants with deformational posterior plagiocephaly had constriction of one or both hemifields by at least 20 degrees from established normal patients. Hemifield asymmetry of 20 degrees or more was found in 17.5% of infants tested. There was a significant difference in the worse hemifield values measured in each patient and the standard visual fields obtained from normative data ( P = 0.036). There was no correlation between the laterality of the visual fields to the laterality of the defects. A correlation between severity of hemifield constriction and % asymmetry on computed tomography was noted ( P = 0.209). Deformational posterior plagiocephaly may affect visual field development but neither the laterality nor the severity of skull deformity is predictive of the severity of visual field defects.

Differential diagnosis of the trapezoid-shaped head.

To recognize several conditions that result in a trapezoid head shape and review and contrast their various physical findings. A detailed review of all patients seen in the Craniofacial Clinic at the Children's Hospital and Regional Medical Center in Seattle, Washington, over a 10-year period from 1991 to 2001, with the diagnosis of craniosynostosis and plagiocephaly was performed. During this period, 690 patients had a surgical correction of craniosynostosis, and 1537 patients had posterior plagiocephaly. The shape of the head when viewed from the vertex position in an axial plane can be a significant diagnostic aid when evaluating a patient with plagiocephaly. Positional molding causes the vast majority of plagiocephaly. This deformational change results in a parallelogram-shaped head. A much more rare cause of plagiocephaly is lambdoid synostosis. With premature fusion of one of the lambdoid sutures, the head takes on a very characteristic trapezoid shape when viewed from the vertex. Unilateral coronal synostosis that occurs on the same side as either posterior positional molding or unilateral lambdoid synostosis will also result in the trapezoid head shape. Furthermore, on the rare occasion when anterior and posterior deformational plagiocephaly occurs on the same side, the trapezoid head shape may be the consequence. The choice of appropriate treatment modality requires systematic evaluation of the patient with a trapezoid-shaped head to determine the etiology of the deformation.

Effects of a child with a craniofacial anomaly on stability of the parental relationship.

The purpose of this study was to determine rates of divorce in parents of children with various types of craniofacial anomalies and to analyze possible confounding factors. A 29-question survey was sent to parents of all children evaluated in the Craniofacial Centre between 1992 and 1997. Parents were questioned regarding pre- and postnatal marital stability, whether the child's facial anomaly contributed to divorce, and involvement in the child's welfare. Using deformational posterior plagiocephaly as a control group, rates of divorce vs. non-divorce were compared for craniofacial anomalies, categorized as asymmetric (hemifacial microsomia, unilateral coronal synostosis, cleft lip, cleft lip/palate) or symmetric (syndromic-craniosynostosis, orbital hypertelorism, Treacher Collins syndrome). Major anomalies (hemifacial microsomia, craniosynostosis, orbital hypertelorism, Treacher Collins syndrome) were also compared to minor anomalies (cleft lip, cleft lip/palate). Surveys were sent to both parents in 412 families; 403 surveys were returned; and the results were evaluated in 275 families (67%). Frequency analysis demonstrated an overall divorce rate of 6.8% and 4.9% separation. Anomalies associated with the highest rate of divorce were hemifacial microsomia (24.0%), syndromic craniosynostosis (12.2%), and cleft lip/palate (6.8%). 79% of non-divorced couples reported a strong prenatal relationship, whereas 59% of divorced couples reported a problematic relationship. Following birth of the affected child, 47% of non-divorced couples responded that the bonds became stronger and 41% of divorced couples thought the relationship worsened. Two-sided Fisher exact test comparing control vs. all other anomalies showed significance (p=.030) for rates of divorce. Separation of anomalies into asymmetric vs. symmetric and major vs. minor categories demonstrated no significant difference in divorce rate (p>.05). The mother was more likely to become a child's primary caregiver following estrangement.

Incidence of cranial asymmetry in healthy newborns.

During recent years, coincident with the recommendation to position infants supine, the incidence of posterior deformational plagiocephaly has increased dramatically. The purpose of our study was to determine whether early signs of cranial flattening could be detected in healthy neonates and to document incidence and potential risk factors. A cross-sectional study was performed in healthy newborns. Physical findings, anthropometric cranial measurements, and data on pregnancy and birth were recorded. The incidence of localized cranial flattening in singletons was 13%; other anomalous head shapes were found in 11% of single-born neonates. In twins, localized flat areas were much more frequent with an incidence of 56%. The following risk factors for cranial deformation were identified: assisted vaginal delivery, prolonged labor, unusual birth position, primiparity, and male gender. We propose that localized lateral or occipital cranial flattening at birth is a precursor to posterior deformational plagiocephaly. The infant lies supine, with the head turned to the flattened area, and is unable to roll. Intrauterine risk factors for localized cranial flattening are the same as for deformational plagiocephaly. To avoid postnatal progression from a localized cranial flattening to posterior-lateral deformational plagiocephaly, we suggest amending the recommendation of the American Academy of Pediatrics on sleep position: Alternate the head position and allow sleeping on the side and, when awake, supervise prone time.

Deformational posterior plagiocephaly: diagnosis and treatment.

This study was designed to evaluate the effectiveness of helmet therapy (DOC band) in the correction of patients with moderate to severe posterior deformational plagiocephaly. In this prospective study, the infants were evaluated using 18 anthropometric measurements. The charts of 248 patients seen between August 1, 1995, and July 31, 1999, were reviewed, and 125 met the criteria for inclusion in the study. All the patients had posterior deformational plagiocephaly with no other craniofacial deformities or medical conditions. Treatment was instituted prior to 1 year of age, and all patients were compliant with DOC band usage and had complete anthropometric measurements. The study recorded a 41.56% (p < .001) reduction in cranial vault asymmetry and a 40.23% (p <.001) reduction in cranial base asymmetry. Orbitotragial asymmetry was improved 18.72% (p = .0738). The age at which treatment was begun was not a significant factor in predicting treatment outcomes.

Deformational Posterior Plagiocephaly: Diagnosis and Treatment

Abstract Objective: This study was designed to evaluate the effectiveness of helmet therapy (DOC band) in the correction of patients with moderate to severe posterior deformational plagiocephaly. Design: In this prospective study, the infants were evaluated using 18 anthropometric measurements. Patients: The charts of 248 patients seen between August 1, 1995, and July 31, 1999, were reviewed, and 125 met the criteria for inclusion in the study. All the patients had posterior deformational plagiocephaly with no other craniofacial deformities or medical conditions. Treatment was instituted prior to 1 year of age, and all patients were compliant with DOC band usage and had complete anthropometric measurements. Results: The study recorded a 41.56% (p < .001) reduction in cranial vault asymmetry and a 40.23% (p < .001) reduction in cranial base asymmetry. Orbitotragial asymmetry was improved 18.72% (p = .0738). The age at which treatment was begun was not a significant factor in predicting treatment outcomes.

Which Misshapen Head Needs a Workup?

Radiology| October 01 2002 Which Misshapen Head Needs a Workup? AAP Grand Rounds (2002) 8 (4): 43–44. https://doi.org/10.1542/gr.8-4-43 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Which Misshapen Head Needs a Workup?. AAP Grand Rounds October 2002; 8 (4): 43–44. https://doi.org/10.1542/gr.8-4-43 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: craniosynostosis, cranium, plagiocephaly, synostosis, synostotic posterior plagiocephaly, well child, craniofacial abnormalities, sleep, radiologists, lambdoid suture Source: Medina LS, Richardson RR, Crone K. Children with suspected craniosynostosis: a cost-effectiveness analysis of diagnostic strategies. AJR. 2002;179:215–221. In this 2 1/2-year prospective study from Miami Children’s Hospital and Children’s Medical Center of Cincinnati of 115 infants presenting with unilateral posterior cranial . attening, only 1 child had synostotic posterior plagiocephaly secondary to lambdoid suture synostosis whereas 114 infants had deformation posterior plagiocephaly. This study was undertaken to evaluate the clinical and economic impact of 3 evaluation strategies in children who differed in their risk of craniosynostosis. Three evaluation strategies used were: no imaging, radiography (if abnormal, was followed by 3-dimensional CT [3D-CT]), and 3D-CT. Three risk groups were analyzed on the basis of the prevalence of disease: low (prevalence 34/100,000); intermediate (healthy children with head deformity, prevalence 1/115); and high risk (children with syndromic craniofacial disorders, prevalence 9–10/10). The results of the analysis were summarized in cost-effectiveness ratios showing the cost of achieving one quality-adjusted life year (QALY) gained for different risk groups and diagnostic strategies. In the low-risk group, the radiographic and 3D-CT strategies resulted in a cost per QALY gained of more than $560,000. In the intermediate-risk group, the radiographic strategy resulted in a cost per quality-adjusted life year gained of $54,600. Three-dimensional-CT was more effective than the other 2 strategies, but at a higher cost with a cost per QALY gained of $374,200. In the high-risk group, 3D-CT was the most effective strategy with a cost per QALY gained of $33,800. Less experienced radiologists and poor quality studies increased the evaluation cost per QALY gained for all of the risk groups. The outcome suggests that radiologic screening of healthy children at low risk for synostosis is unwarranted; in healthy children with a head deformity at intermediate risk, the radiographic strategy has a reasonable cost per QALY gained, with 3D-CT more effective but with higher cost per QALY. In children with syndromic craniofacial disorders who are at high-risk, 3D-CT is the most effective strategy and has a reasonable cost per QALY gained. Children with high-risk, syndrome-related craniosynostosis should be evaluated thoroughly with imaging performed and interpreted by experienced radiologists. This group will benefit from early intervention. Craniosynostosis, the early fusion of skull sutures, requires an accurate diagnosis before treatment. Both isolated and syndrome-related craniosynostosis contribute to the prevalence in the general population of 34 to 48 per 100,000 live births with nonsyndromic causes being the most common.1,2 Sagittal suture synostosis accounts for 56% of cases with coronal suture synostosis accounting for 22%.1 In the last 10 years there has been an exponential increase in infants with deformational posterior cranial plagiocephaly, likely related to the recommendation that infants sleep in the supine position and increased general awareness of plagiocephaly. Appropriate management of posterior plagiocephaly3 requires differentiation of occipitoparietal flattening caused by lambdoid synostosis from deformation due to external forces. In view of the very high costs of imaging required for early management of craniosynostosis, this cost-effectiveness analysis provides... You do not currently have access to this content.

Anthropometric analysis of mandibular asymmetry in infants with deformational posterior plagiocephaly

Purpose: The incidence of deformational posterior plagiocephaly has increased dramatically since 1992. We tested the hypothesis that mandibular asymmetry, associated with this condition, is secondary to anterior displacement of the ipsilateral temporomandibular joint. The response to molding helmet therapy was also evaluated. Patients and Methods: A caliper was used to measure mandibular dimensions in 27 infants (16 boys and 11 girls) with deformational posterior plagiocephaly; the mean age was 6.2 months (range, 3 to 12 months). Anthropometric measures included ramal height (condylion-gonion), body length (gonion-gnathion), and condylion-gnathion. Gonial angle was calculated from the law of cosines: C2 = A2 + B2 − 2AB cos c. The position of the temporomandibular joint was accepted as corresponding to auricular position and measured from tragion to subnasal. Cranial asymmetry was measured, in the horizontal plane, from orbitale superius to the contralateral parieto-occipital point at the level of inion. Ten of 27 patients were remeasured 5 months after beginning helmet therapy to evaluate change in mandibular dimensions. Results: Two thirds of infants (67%) had right-sided and one third (33%) had left-sided deformational posterior plagiocephaly. The mean auricular anterior displacement was 79.7 mm on the affected side and 83.4 mm on the unaffected side. The mean difference of 3.8 mm between the sides was statistically significant (P <.001). Transverse cranial dimension averaged 136.0 mm on the affected side and 146.8 mm on the unaffected side; this was also significant (P <.001). There was a significant positive correlation between auricular displacement and cranial asymmetry [R(23) =.59, P <.01). Auricular (temporomandibular joint) displacement also resulted in an apparent mandibular asymmetry with rotation of the jaw to the affected side. Mean mandibular measurements on the affected and unaffected sides were ramus height of 35.2 and 36.4 mm, body length of 59.0 and 60.3 mm, and gonial angle of 127.1° and 126.8°, respectively. Comparison of the affected with the unaffected sides, using a paired-samples t test, was not statistically significant. Improvement in cranial asymmetry occurred with helmet therapy, but there was no correction of auricular and temporomandibular joint position. Conclusions: This study supports the clinical observation that the mandibular asymmetry in deformational posterior plagiocephaly is secondary to rotation of the cranial base and anterior displacement of the temporomandibular joint (quantified by anterior auricular position) and not the result of primary mandibular deformity. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:873-877, 2002