Working out funny head postures

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Working out funny head postures

• LIONEL KOWAL
• RVEEH, CERA, Melbourne 2005

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Abnormal Head Posture T3

• Always 3 components to look for and explain
• TILT - to L or R HT head tilt
• TURN - to L or R FT face turn
• TIP - up or down

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TILTSQ1 Is HT driven by visual activity?

• Instruction to patient
• Close your eyes and hold your head straight.
• Uncertain response pt closes eyes, Dr tilts head
  randomly, pt asked to straighten head

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Both eyes closed - HT persists

• HT not related to visual activity!
• Causes Vestibular problem / ocular tilt
  reaction / tectal pathology/ neck problems
• Have seen dysplastic vermis as a cause of HT
  beginning age 6 mo

Eyes closed
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BE closed - HT goes

• HT driven by visual activity
• Now determine Is HT driven by
• Right eye fixing RF
• Left eye fixing LF
• Either eye fixing EE
• Only when both eyes are fixing BE

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Either eye drives HT

• Congenital nystagmus with oblique null
• Look for other features of CN - horizontal jerk
  nystagmus, convergence null, recordings,
• CN the cong nystag seen with sensory
  developmental disorders - OCA, CSNB, ONHypo,
• De Decker or Sousa Dias for treatment guidelines
• Sub clinical micronystagmus only detectable by
  eye movement recordings has been described - I
  havent seen it

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Special caseHead tilt to fixing eye

• LF drives HT to L
• RF no HT
• 2 causes
• 1. Torsional LMLN
• 2. L Orbital reasons

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LF drives HT to L1. Torsional LMLN

• LMLN is the cong nystag seen with disorders of
  binocular development
• ?always Seen in cong ET
• Fixation Maldevelopment N.
• Usually has H component, sometimes T as well
• Fine torsional N on slit lamp
• N degrades vision - vision improves when N
  blocked

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1. How to block Torsional LMLN to improve vision

• HT to fixing eye recruits Sup Obl which acts as a
  brake on produces a null for T component of
  the LMLN. Braking T LMLN ? better vision
• Looks like Preference for fixation in intorsion
• HT usually driven by the dominant eye but can
  be the wrong eye
• The same mechanism is part of the causation of
  contra lateral DVD - see Guyton

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Special caseAlternating Head Tilt

• LF drives L tilt
• RF drives R tilt
• Ciancias syndrome

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Ciancias Syndrome

• H T LMLN are frequent ?universal associations
  of cong ET
• Ciancias S Regular cong ET where the
  consequences of T H LMLN are a prominent part
  of the clinical picture in addition to the ET
• Consequences head tilts, face turns, DVD, DHD,
  
• Associations PVL, Downs, after IVH / H-ceph,

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Ciancias Syndrome

• Head tilt / face turn recruits a muscle to block
  the T / H component of LMLN ? improves vision
• T HT to fixing eye - recruits Sup Obl to brake
  T LMLN
• H FT to fixing eye - recruits Medial Rectus to
  brake H LMLN

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LF drives HT ? L2. Orbital reason

• Orbital scarring
• Restrictive strabismus esp.... Graves
• Motor reasons
• 2? Sensory reasons - acquired astigmatism from
  tight muscles

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HT driven by binocularity

• RF LF no HT
• Strabismus the cause
• Tilt R and do a cover test to discover the cause!

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RF ? Head Tilt to L

• Problem with R orbit

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Still cant explain the head tilt

• Spasmus nutans - always has monocular N - can be
  difficult to see - can look like shimmering.
• No explanation Low threshold for imaging

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Still cant explain the head tilt

• Check again when a human being examines
  another, signs not always perfect
• Habit, psychological, after full
• investigation, these are synonyms for
• HT due to an unknown non sinister non-
  treatable cause

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Face Turn - L

• Approach the same way as tilt - a few differences
• Is the FT visually driven Close your eyes and
  hold your head straight
• If its visually driven, is it driven by
• LF RF EE BE ?

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Face Turn - Left

• If driven by
• LF Fixation- in- adduction for horizontal LMLN
  or L orbital problem
• RF R orbital problem
• EE cong nystagmus
• BE strabismus

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Alternating Face Turn2 causes1. Ciancias
syndrome

• LF L FT
• RF R FT
• Ciancias syndrome preference for fixation in
  adduction because recruiting medial rectus
  brakes horizontal component of LMLN ? improved
  vision

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Alternating Face Turn2. Periodic alternating
nystagmus

• Regular CN with 2 H null zones
• Much more frequent than suspected esp.....
  albinism
• CAREFUL Family Album Test ANY photos showing FT
  ? R suggest PAN

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Alternating Face Turn2. Periodic alternating
nystagmus

• Usually asymmetric periodicity aperiodic say,
  90 FT ? L, 10 FT ? R
• Prolonged in- office exam

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Astigmatism

• Wrong cyl axis can ? HT
• Uncorrected astigmatism pt uses corner of
  palpebral fissure as pinhole ? FT

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TIP UP / DOWN

• Same principles as HT / FT what drives the Tip?
  RF, LF, EE, BEO
• Some different diseases cause Tips
• LMLN not involved

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TIP Driven by Either Eye

• Supranuclear vertical gaze paresis
• variable causes and expectations
• Spino Cerebellar Atrophy SCAs - acquired null
  for acq Downbeat N

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TIP Driven by Either Eye

• CN usu H, rarely V with vertical null
• see Delmonte
• CFEOM if bilateral / symmetric looks like
  restrictive strabismus

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TIP driven by one eye fixing

• This is due to orbital reasons, typically a tight
  or deficient muscle

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TIP DRIVEN BY BEO

• Strab esp. alphabet patterns

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Variable HT/ FT/ Tip

• CN can have different null zones e.g. FT and Tip
  both effective. Fixing one can release another.
  
• Null zones in CN not always hard wired - can
  vary with time rare and during the one
  examination very rare

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Working out head tilts face turns

• Working out head tilts can be easy, difficult or
  near- impossible. It is always interesting!
• Thank you!

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Working out head tilts face turns

• THANK YOU