Abnormal head position

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

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

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

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
    • Gorlins Syndrome
    • Other familial genetic syndromes
  • Neurological examination (include assessment of vision (including acuity), gait and coordination)
  • Full visual assessment
  • Plot growth for all children and pubertal status if applicable
  • Plot head circumference in children under two

Worrying features

  • Persistent head tilt with no resolution