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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>?

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