A Case Study Of Deformational Plagiocephaly Associated With Ocular Torticollis

Phillip M Stevens, MEd,
CPO Specialized Prosthetic and Orthotics Technologies
Salt Lake City, Utah

Current literature has clearly defined both the cranial and facial asymmetries associated with deformational plagiocephaly. Cranial asymmetries are described as a parallelogram-like shape in which there is distinct flatness of the occipital quadrant upon which the weight of the head is born. Concomitant bossing or bulging on the contralateral occipital quadrant also results from the abnormal pressures crated by this positioning. Ipsilateral to the occipital flatness there is often a protrusion of the forehead. Ear asymmetry is typically observed with the ear ipsalateral to the occipital flattening and frontal bossing located anterior to the contralateral ear. Regarding facial asymmetries, authors have identified minor inferior displacement of the ipsilateral supraorbial rim, a relatively recessed or flattened ipsilateral malar eminence, and ipsilateral deviation of the chin point(1).

Given the close association between congenital muscular torticollis (CMT) and deformational plagiocephaly, it is not surprising to note similarities in their respective facial asymmetries. Those reported with respect to CMT include relative retrusion of the forehead and zygoma ipsilateral to the affected sternocleidomastoid muscle, posteriorinferior displacement of the ipsilateral ear, deviation of the chin point ipsilaterally, and in advanced cases, a reduction in vertical facial height on the ipsilateral side(2).

The case subject presented with cranial asymmetries consistent with deformational plagiocephaly. However, the subject's observed facial asymmetries were inconsistent with those in the literature. Further questioning reveals that the subject was diagnosed with superior oblique palsy (SOP) which in turn resulted in an ocular torticollis. Second only to CMT in infantile prevalence, the various types of ocular torticollis are characterized by a persistent head posturing secondary to ocular misalignment to maintain binocular vision. In the case of SOP, the head tilts away from the paralyzed side to accommodate the ocular defects.

As with deformational plagiocephaly and CMT, the current literature has identified certain facial asymmetries common to infants with SOP. These include as "midfacial hemihypoplasia" in which the dependent side of the face is vertically shorter with a lower orbit and higher corner of the mouth. The nose and mouth deviate toward the hypoplastic side, consistently observed ipsilateral to the cervical tilt (3-5). Our case subject's facial asymmetries were consistent with these findings.

The significance of a case subject with both deformational plagiocephaly and ocular torticollis are two fold. First, it seems reasonable to suggest that the deformational plagiocephaly might have been induced by the ocular torticollis as the accommodative head tilt resulted in either a positioning preference or muscle imbalance predisposing the subject to iterative positional forces. Secondly, while the etiologies of midfacial hemihypoplasia associated with SOP are unclear, it seems unlikely that they resulted from deformational forces given that they developed in our case subject, not because of deformational forces, but in spite of them.

References

  1. Bruneteau RJ and Mulliken JB. Frontal plagiocephaly: Synostotic, compensational or deformational. Plastic Reconstr Surg. 1992;89(1):21-31.

  2. Hollier L, Kim J, Grayson BH, McCarthy JG. Congenital muscular torticollis and the associated craniofacial changes. Plast Reconstr Surg. 2000 Mar;105(3):827-35.

  3. Williams CRP, O'Flynn E, Clarke NMP, RJ Morris. Torticollis secondary to ocular pathology. J Bone Joint Surg [Br] 1996;78-B:620-4.

  4. Rubin SE, Wagner RS. Ocular Torticollis. Surv Ophthalmol 1986;30(6):366-376.

  5. Paysee EA, Coats DK, Plager DA. Facial asymmetry and tendon laxity in superior oblique palsy. J Pediatr Ophthalmol Strabismus 1995;32:158-161.