Dr. Eric Lichtenstein: Torticollis & Nystagmus - ENT & Allergy ...
Dr. Eric Lichtenstein: Torticollis & Nystagmus - ENT & Allergy ...
Dr. Eric Lichtenstein: Torticollis & Nystagmus - ENT & Allergy ...
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Abnormal Head PositionAbnormal Head Position<strong>Eric</strong> A. <strong>Lichtenstein</strong>, MD FAAP
<strong>Torticollis</strong>tortuscollumtwistedneck
TiltHead tilt
TurnFace turn
Chin up
Chin down
Abnormal Head Position (AHP)Tilt headTurn faceChin up/down
Ocular AHPadaptive mechanismneck control required
Ocular AHP: AdaptationStrabismus(avoid double)Ptosis(seek stereo)<strong>Nystagmus</strong>(improve acuity)
Ocular AHPDouble vision (strabismus)Stereo acuity (ptosis)Visual acuity (nystagmus)Not issues during sleep
AHP HxDoes AHP persist with sleep?Ocular: noHow old when AHP began?Ocular: 3 to 4 months
AHP d/dx• Muscular/skeletal• Auditory• Ocular
Ocular AHPStraighten the headStrabismus?Ptosis?<strong>Nystagmus</strong>?
Ocular AHPStrabismusPtosis<strong>Nystagmus</strong>
AHP: StrabismusAvoid double visionEnhance depth perception
StrabismusComitantAngle same in every gazeAHP: no benefitIncomitantAngle varies with gazeAHP: may benefit
Incomitant strabismusA/V PatternsDuane SyndromeCranial Nerve PalsiesMiscellaneous
A-pattern: Chin Up
A-pattern
V-pattern: Chin Down
V-pattern
Duane syndromeSynkinesis 3 rdrd/6 ththnerveCo-contraction(medial/lateral recti)CongenitalHearing deficits
Duane syndrome
Duane syndromeAD-duction (looking in) – lids close
Duane syndromeAB-duction (looking out) – lids open
Duane syndromeLid height changes with gaze
Duane syndrome
Duane syndrome
Duane syndrome
Duane syndrome
Duane SyndromeBefore surgeryAfter surgery
Duane Syndrome?8 mo healthy ♂Acute onset AHPURI 1 week prior
Duane SyndromeAcute onsetPoor AB-duction ALid height constant
Post-viral 6th Nerve Palsy: Observe4 months later 11 months later
6th Nerve Palsy: When to ScanNot post-viralNot isolatedany other cranial nerveany descending tract paresis/palsyMotor or other developmental delay
Most common CN AHP4th Nerve “Palsy”Abnormal rotation:Lax SO tendonNot actually a palsy
Congenital SOP = Tendon Laxity
2/3 of adults withSOP are congenitalcasesNeck and facechanges
Mid-facialhemi-hypoplasiahypoplasia
Ocular AHPStrabismusPtosis<strong>Nystagmus</strong>
Ptosis
Ptosis
Ptosis
Ocular AHPStrabismusPtosis<strong>Nystagmus</strong>
<strong>Nystagmus</strong>Involuntary rhythmic oscillationConjugate : same directionDysconjugate: different directions
<strong>Nystagmus</strong>AmplitudeFrequencyMagnitude = Amplitude x FrequencyNull zone: where magnitude is least
Horizontal, conjugate nystagmus.
Horizontal, dysconjugate nystagmus.
Dysconjugate nystagmus.
Vertical, conjugate
Vertical, Dysconjugate(see-saw)saw)
<strong>Nystagmus</strong>Can be benignCan herald CNS mass“Safe” -horizontal in all directions of gazepresent “since birth”decreases with near viewing** albinism
Horizontal, conjugate nystagmus.
BenignCongenital Motor <strong>Nystagmus</strong>“Safe” -- horizontal in all directions of gazepresent “since birth”decreases with near viewingNull zone evident (AHP present)
BenignCongenital Motor <strong>Nystagmus</strong>“Safe” -- horizontal in all directions of gazepresent “since birth”decreases with near viewingNull zone evident (AHP present)
Null zone<strong>Nystagmus</strong> dampened by gazeAHP utilized to look into null zoneCan change early in lifeCan be shifted (surgery)
<strong>Nystagmus</strong>AHPPost-opop
<strong>Nystagmus</strong>AHPPost-opop
<strong>Nystagmus</strong>AHPPost-opop
<strong>Nystagmus</strong>AHPPost-opop
<strong>Nystagmus</strong>AHPPost-opop
Ocular AHPStraighten the headStrabismus?Ptosis?<strong>Nystagmus</strong>?