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Quality Education for a Healthier Scotland
Multidisciplinary
“Your face, my thane is as a book…”
Macbeth
Promoting multiprofessional education and development in
Scottish maternity care
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Quality Education for a Healthier Scotland
MultidisciplinaryObjective:
to detect the commonest abnormalities of the
• face• eye• ear and hearing• mouth to review their significance in the newborn and refer
appropriately.
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Quality Education for a Healthier Scotland
Multidisciplinary Structure of the talk
•Face size vs Head•Symmetry and Position•Abnormal Eyes•Abnormal Ears•Nose and Lips•Abnormal Mouth•Abnormal Palate.
The Face
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Face:
Whole Picture
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Quality Education for a Healthier Scotland
MultidisciplinarySymmetry and Position
Facial Palsy:Commoner afterforceps delivery Compression effect of the forceps on the branch of the facial nerve is often transient, and total recovery is usually anticipatedLook for other injuries.
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Quality Education for a Healthier Scotland
MultidisciplinarySymmetry and Position
Asymmetric crying faces:
Congenital lack of normal innervation to mid faceAssociation with cardiac disease.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Face: Trauma
Petechiae and bruising
Congestion common in face to pubes presentation
This bruising from bleeding under deep layers of scalp.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Eye
•Normal Lids•Overall size•Symmetry/position•Round iris•Pupil/lens•Red light reflex/retina.
Normal eye
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Eyelids
Swelling from deliveryBruising Sub-aponeuroticInfection.
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Quality Education for a Healthier Scotland
Multidisciplinary
The Eye
Coloboma:
Is a defect in the closing of the globe Ranges in severity from a notch in the lower part of the iris, making the pupil pear–shaped, to defects behind the iris in the fundus.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Eye
With your ophthalmoscope set to +3 dioptres examine the cornea, iris and red reflex from a distance of approx 20 cm.
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Quality Education for a Healthier Scotland
MultidisciplinaryRed reflex
An abnormal red reflex requires an urgent ophthalmologic opinion as it may represent a cataract or a mass of abnormal tissue.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe White Eye/Leukocoria Cataract
•The lens does not allow light through to illuminate the retina•May be tiny central dots.
Familiale.g. Galactokinase deficiency.
retinoblastoma
Retinoblastoma
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Quality Education for a Healthier Scotland
MultidisciplinaryThe White Eye
Primary persistent vitreous
The solid tissue which formed the globe of the eye has persisted leaving permanent blindness and glaucoma.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Eye
Congenital glaucoma
Obstruction to outflow of fluid from the eyeLarge hazy eye.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Eye
Blocked Lacrimal Duct
Resolve <12 months>12 months refer to ophthalmologist for possible probing.
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Quality Education for a Healthier Scotland
MultidisciplinaryDacrocystoceles
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Quality Education for a Healthier Scotland
MultidisciplinarySquashed nose
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Nose
Choanal Atresia:
This can be one or both sides, bony or membranous
Usually presents with cyanosis when not crying.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Nose
Snuffles
Noses can be partially blocked by vernix, blood, milk, etc.
Later low grade bacterial sepsis can be a problem.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear
•Size•Shape•Position•Abnormalities•Extra bits.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear Position
Low setNormal
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Quality Education for a Healthier Scotland
MultidisciplinaryLow Set Ears
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear
ShapeBranchial arch anomalies with unusual ears, small mandiblesOto-renal syndromes with unusual ears, fistulae in neck and renal problems.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear
SizeTrisomy 18 with small abnormal and low set earsPotter’ syndrome: Renal problems leading to oligohydramnios and a squashed baby.
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Quality Education for a Healthier Scotland
Multidisciplinary
Ear position and shape
As in CHARGE syndrome.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear
Pre-auricular pits or small fistulae.This baby’s mother had a similar pit but on the other side.There were no associated problems in this case.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Ear
Skin tagsSimple tags are usually only cosmetic.Multiple or large tags can indicate hearing abnormalities or syndromes.Formal excision is usually recommended.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Mouth
GumsTonguePalate
HardSoft.
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Quality Education for a Healthier Scotland
Multidisciplinary
Tongue tie
CommonNot usually divided unless interfering with feedingPossible late association with speech problems.
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Quality Education for a Healthier Scotland
MultidisciplinaryRanulae
Mucous inclusion cysts in the sublingual salivary glands on the floor of the infants mouth.They are usually small and will spontaneously regress. Larger ones need surgical removal.
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Quality Education for a Healthier Scotland
MultidisciplinaryEpstein's Pearls
Nodules of epithelial cells resembling pearls just lateral to the midline on the hard palate (with a cluster at the junction of the hard and soft palate) are a normal finding.
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Quality Education for a Healthier Scotland
Multidisciplinary
Neonatal teeth
Usually superficial in the gum and are removed to avoid maternal nipple problems.
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Mouth
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Quality Education for a Healthier Scotland
Multidisciplinary Cleft Lip and or palate = 1 / 700 births
53% Isolated Cleft Soft (2°) Palate
Cleft palate80% Isolated deformityFamilial 12%Syndromic 8%
Affected sib = x 3.5 Two sibs = x 13.
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Quality Education for a Healthier Scotland
MultidisciplinaryCleft PalateHigh Risk
Family HistoryMaternal exposure to teratrogens
incl. Anti-convulsants, steroids, alcoholSyndromes, e.g.Trisomy13,18Infant of diabetic mother (Χ2)Milk coming down nose during feeds.
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Quality Education for a Healthier Scotland
MultidisciplinaryCleft palate
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Quality Education for a Healthier Scotland
MultidisciplinaryCleft palate
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Quality Education for a Healthier Scotland
MultidisciplinaryCleft uvula
A small posterior cleft palate is often missed. The bifid uvula seen here points towards a sub mucous cleft.
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Quality Education for a Healthier Scotland
MultidisciplinaryCleft lip and palateUnilateral.
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Quality Education for a Healthier Scotland
Multidisciplinary
Cleft lip and palateBilateral.
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Quality Education for a Healthier Scotland
Multidisciplinary
Cleft Palate - Examination
Spontaneous visualisation bestPalpation with little finger of hard and soft palateVisualisation during gagHIGH RISK group only - use laryngoscope.
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Quality Education for a Healthier Scotland
Multidisciplinary
Any questions?
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Quality Education for a Healthier Scotland
MultidisciplinarySummary
Follow your instincts about a funny-looking face, but it may be familial!
One abnormality may follow another – remember associations esp. hearing.
If there is an increased risk of a cleft palate – formally view the soft palate.
Kind thanks to Janelle Aby, MD for many of the photographs