quality education for a healthier scotland multidisciplinary “ your face, my thane is as a book...

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

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.

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

Quality Education for a Healthier Scotland

MultidisciplinaryThe Face:

Whole Picture

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.

Quality Education for a Healthier Scotland

MultidisciplinarySymmetry and Position

Asymmetric crying faces:

Congenital lack of normal innervation to mid faceAssociation with cardiac disease.

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.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Eye

•Normal Lids•Overall size•Symmetry/position•Round iris•Pupil/lens•Red light reflex/retina.

Normal eye

Quality Education for a Healthier Scotland

MultidisciplinaryThe Eyelids

Swelling from deliveryBruising Sub-aponeuroticInfection.

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.

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.

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.

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

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.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Eye

Congenital glaucoma

Obstruction to outflow of fluid from the eyeLarge hazy eye.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Eye

Blocked Lacrimal Duct

Resolve <12 months>12 months refer to ophthalmologist for possible probing.

Quality Education for a Healthier Scotland

MultidisciplinaryDacrocystoceles

Quality Education for a Healthier Scotland

MultidisciplinarySquashed nose

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.

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.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Ear

•Size•Shape•Position•Abnormalities•Extra bits.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Ear Position

Low setNormal

Quality Education for a Healthier Scotland

MultidisciplinaryLow Set Ears

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.

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.

Quality Education for a Healthier Scotland

Multidisciplinary

Ear position and shape

As in CHARGE syndrome.

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.

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.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Mouth

GumsTonguePalate

HardSoft.

Quality Education for a Healthier Scotland

Multidisciplinary

Tongue tie

CommonNot usually divided unless interfering with feedingPossible late association with speech problems.

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.

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.

Quality Education for a Healthier Scotland

Multidisciplinary

Neonatal teeth

Usually superficial in the gum and are removed to avoid maternal nipple problems.

Quality Education for a Healthier Scotland

MultidisciplinaryThe Mouth

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.

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.

Quality Education for a Healthier Scotland

MultidisciplinaryCleft palate

Quality Education for a Healthier Scotland

MultidisciplinaryCleft palate

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.

Quality Education for a Healthier Scotland

MultidisciplinaryCleft lip and palateUnilateral.

Quality Education for a Healthier Scotland

Multidisciplinary

Cleft lip and palateBilateral.

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.

Quality Education for a Healthier Scotland

Multidisciplinary

Any questions?

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