Abnormal Head Tilt
In the eyes of every parent, a new baby is a beautiful and perfect miracle. New parents count fingers and toes, watch reverently as their little one eats and sleeps, and gently stroke the silky hair that covers the tiny head. From the instant of birth, parents begin the mental checklist of developmental milestones: first smile, first time that the baby holds up his head, first night of uninterrupted sleep (for both baby and parents!). Every moment is documented by photograph and video, affording the pediatric ophthalmologist with concrete evidence of when, and sometimes why, an abnormal head position, or torticollis, develops.
Torticollis is a condition in which the head is not straight relative to the rest of the body. It may be turned to the right or left, raised so that the chin is in the air or lowered so that the chin is tucked, tilted to either shoulder, or it may occur as a combination of any of these positions. The abnormal head position may be apparent as soon as a baby steadily holds up his head, generally at the age of 3 to 4 months. There are a number of causes for torticollis, so identifying the problem, and diagnosing why it is present, is essential for proper treatment to be performed. It also avoids the discomfort of neck pain that is frequently a consequence of a chronic abnormal head position, especially in adulthood.
Torticollis may be present at birth, or occur early in infancy. It may be caused by tightness in neck muscles or by abnormalities in the vertebrae of the neck. Abnormal head positions may also be caused by deafness, or a significant hearing loss, in one ear. The baby will turn or tilt his head to the affected side, placing the ear with better hearing in a position to amplify the sounds around him. An ENT (ear, nose and throat) specialist should be enlisted to determine the cause and extent of the hearing deficit.
An abnormal head position can also be caused by certain eye problems. A simple test, covering one eye and then the other, usually with an adhesive patch, will often differentiate between an eye problem and non-ocular causes as the culprit. If the head straightens with either eye covered, eye problems must be suspected and investigated. For example, a child with a head tilt to the right shoulder may have a tightness of the right neck muscle that won’t allow the head to straighten. A patch placed over either eye will not affect the head tilt.
However, the head tilt might be caused by an eye muscle problem called superior oblique paresis. Any head injury, even the mildest bump to the head, might injure the IVth cranial nerve, the nerve supply for the superior oblique muscle. Injury to the nerve may cause double vision and an elevation of the affected eye. The head tilt restores use of the eyes together and preserves depth perception. A patch placed over the eye with the injured superior oblique muscle should cause the head straighten, while the head tilt will remain when placed on the unaffected eye.
Drooping of the eyelids may involve one or both eyes. If the line of sight is blocked by the drooping eyelid, then the baby will raise his chin to see. Surgery on the drooping eyelids will be necessary for the vision to develop normally and to avoid neck muscle problems.
Eye muscle disorders, both present at birth or acquired, often go together with an abnormal head position. Each eye has six muscles that move the eyes, and these are operated by three cranial nerves that travel through the brain. An eye muscle disorder may not affect all positions of gaze: the baby will place his eyes in a position where the eyes are used together, and fusion and depth perception are present.
The fourth cranial nerve, also called the trochlear nerve, may be damaged through birth trauma or as a consequence of a childhood bump to the head. Injury to this nerve will usually cause the baby to adopt a head tilt towards the unaffected eye. Photographs or videos, referred to by eye care professionals as “Family Album Tomography”, or “FAT scan”, are extremely useful in determining the onset of this eye muscle disorder: they are frequently more telling than the parents’ observations!
Nystagmus is a wiggling of one or both eyes. The eye movement may be quite obvious, or very subtle. The wiggling of the eyes is more often on a horizontal plane that is side-to-side, although the wiggling may also be up and down. Vision is frequently decreased. A baby will adjust his head to place his eyes in a position where the movement is least pronounced, because that is where the vision is best. Certain types of nystagmus that are accompanied by abnormal head positions respond well to eye muscle surgery. This is often performed once the child’s vision is able to be tested accurately, between the ages of 4 and 5 years.
In summary, many different reasons may cause babies to adopt an abnormal head position, also called torticollis. Correctly diagnosing the root problem may take the expertise of several specialists and several visits, but appropriate treatment will have a major impact on the baby’s growth and development.
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