headsmartjordan

Abnormal head

position

Reassure

• Head tilt is abnormal - you can only reassure once an underlying aetiology is found
• Cause will either be:
• Local congenital sternocleidomastoid mass
• Local infective cause e.g. lymphadenitis
• Visual problem
• Tumour at base of the neck

Action

Course of antibiotics if thought to be infective with review two weeks after onset Physio referral if local

Review/refer

• Head tilt or torticollis less than two weeks
• Normal visual assessment
• No corroborating findings of ENT or lymph node infection
• Any worrying features
• No/little improvement following postural advice

Action

Observe and review two weeks after vomiting onset Repeat history and examination

Scan

• Unresolved/persistent head tilt or torticollis with no identified cause
• Head tilt with one or more other symptoms suggestive of brain tumour
• Head tilt with associated high risk condition
• Head tilt with abnormal neurological or visual examination

Action

Refer for an MRI scan

Diagnostic pitfalls

• Attributing torticollis or head tilt to a local cause without corroborating features.

Examination/assessment

• Determine duration of head tilt or torticollis.

• Assess ENT

• Ask specifically about associated symptoms and risk factors:

• Personal or family history of a brain tumour
• Leukaemia
• Sarcoma and early onset breast or bowel cancer prior therapeutic CNS irritation
• Neurofibromatosis types 1 and 2
• Tuberous Sclerosis
• Li Fraumeni Syndrome
• Family history of colorectal polyposis

• Neurological examination (include assessment of vision (including acuity), gait and coordination

• Full visual assessment

• Plot growth for all children and pubertal status if applicable

Worrying features

• Persistent head tilt with no resolution

Abnormal head

position

Reassure

Action

Review/refer

Action

Scan

Action

Diagnostic pitfalls

• Attributing torticollis or head tilt to a local cause without corroborating features.

Examination/assessment

• Determine duration of head tilt or torticollis.

• Assess ENT

• Ask specifically about associated symptoms and risk factors:

• Personal or family history of a brain tumour

• Leukaemia

• Sarcoma and early onset breast or bowel cancer prior therapeutic CNS irritation

• Neurofibromatosis types 1 and 2

• Tuberous Sclerosis

• Li Fraumeni Syndrome

• Family history of colorectal polyposis

• Neurological examination (include assessment of vision (including acuity), gait and coordination

• Full visual assessment

• Plot growth for all children and pubertal status if applicable

Worrying features

• Persistent head tilt with no resolution

Persistent/recurrent headache

Balance/co-ordination/walking problems

Persistent/recurrent vomiting

Abnormal eye movements

Blurred or double vision/loss of vision

Behaviour change

Fits or seizures

Abnormal head position such as wry neck, head tilt or stiff neck

Delayed puberty

Increasing head circumference

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