HEENT neonatal assessment

• Performing a systematic inspection of the HEENT (head, eyes, ears, nose, throat [mouth and neck]) system involves skills of acute observation, paying close attention to symmetry and placement of facial features, and palpation. As always, identification of risk factors from the maternal/family/intrapartum history provides an indication of the need for further testing/evaluation. Many facial features provide clues to genetic conditions. Because the head is the presenting part at many deliveries, understanding of normal and abnormal scalp swellings is important to provide explanations to parents about what they are seeing in their infant, as well as any further testing/evaluation that is indicated.
• Head: evaluate the shape, presence, and distribution of hair, scalp defects, abnormal lesions or protuberances, lacerations, and abrasions or contusions.
• Head circumference measure should be performed at delivery, and then on a routine basis to assess brain growth.
• Palpation and measurement of anterior and posterior fontanelles should be performed at delivery and with every physical assessment. It provides information about intracranial pressure, as well as possible congenital conditions. Providers should understand how to measure them, what is normal, and when they are expected to close.
• Since lumps and bumps on the head may arise from soft tissue or bone and can be firm, hard, or soft, and many are common in newborn infants, palpation of cranial bones/evaluation of sutures is an important skill in order to differentiate between normal findings, variations, or congenital conditions that require further evaluation. Early identification of cranial bone anomalies can improve outcomes and prevent the need for surgical intervention.
• In addition to observation and palpation, occasionally, auscultation of the skull (through the anterior fontanelle) for a bruit is helpful to detect an arteriovenous malformation. Transillumination of the skull can help identify suspected intracranial defects, such as hydranencephaly and hydrocephalus,
• The texture, pattern, and amount of scalp hair may suggest an underlying problem. Low hairlines can be consistent with genetic anomalies.
• Face: evaluate size, shape, position, and symmetry (including of movement) of facial features, including mouth, lips, philtrum, nose, eyes, eyelids (lashes), palpebral fissures, and pinnae may reveal a phenotypic pattern consistent with a syndrome or a genetic/chromosomal abnormality.
• Swellings can be related to trauma or an infectious process.
• Understanding how to utilize the ophthalmoscope to evaluate a red reflex is critical to screen for ophthalmic conditions that, if left untreated, could lead to irreversible visual loss, blindness, and even death.
• Ear placement, formation, along with the presence of preauricular skin tags and pits can indicate a syndrome or genetic anomaly, or a possible hearing deficit (conductive, neurosensory, or both). Otoscope evaluation in the newborn is not routinely performed. Evaluation of family history along with a hearing screen should be performed on every newborn before hospital discharge, accompanied by audiology referral if they do not pass.
• In addition to the size and shape of the nose, evaluation of the patency of the nasal airway is done. Nasal stuffiness or discharge can arise from an infectious process, maternal substance use, trauma (including from routine suctioning), or congenital anomaly. Nasal flaring can be an indication of respiratory distress.
• Neck: observe and palpate to evaluate for movement, webbing, cysts, masses, redundant posterior neck folds, and length. The presence of these can indicate a need for further evaluation for genetic conditions, or a need for physical therapy. Early identification of torticollis can improve outcomes and prevent the need for surgical intervention.

Objectives

• Week 4: HEENT Assessment

1. Differentiate between normal and abnormal parameters of the head, eyes, ears, nose, mouth, and neck exam measurement, inspection, auscultation and transillumination.
2. Integrate knowledge of birth trauma findings and craniofacial malformations with need for further evaluation/treatment.

Required Readings and Viewing

• Attached Files:
• (1.138 MB)
• (1.088 MB)
• (783.766 KB)

1. Tappero chapter 5.
2. Ramasubramanian, A., & Johnston, S. (2011). Neonatal eye disorders requiring ophthalmology consultation. Neoreviews, 12, e216. DOI: 10.1542/neo.12-4-e216 (see attached)
3. Sun, M., Ma, A., Li, F., Cheng, K., Zhang, M., Yang, H., . . . Zhao, B. (2016). Sensitivity and specificity of red reflex test in newborn eye screening. J Pediatr, 179, 192-196 e194. doi:10.1016/j.jpeds.2016.08.048
4. Roth, D. A., Hildesheimer, M., Bardenstein, S., Goidel, D., Reichman, B., Maayan-Metzger, A., & Kuint, J. (2008). Preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns. Pediatrics, 122(4), e884-890. doi:10.1542/peds.2008-0606
5. Furdon, S. & Clark, D. (2001). Differentiating scalp swellings in the newborn. Adv Neonatal Care, 1, 22-27. doi: 10.1053/adnc.2001.27779
6. Merritt, L. (2005). Part 2. Physical assessment of the infant with cleft lip and/or palate. Adv Neonatal Care, 5(3), 125-134. DOI: 10.1016/j.adnc.2005.02.006
7. Tighe, T., Petrick, L., Cobourne, M.T., & Rabe, H. 2011. Cleft lip and palate: Effects on neonatal care. Neoreviews,12;e315
8. Merritt, L. (2009). Recognizing craniosynostosis. Neonatal Netw, 28(6), 369-376.
9. Gandolfi, B. M., Sobol, D. L., Farjat, A. E., Allori, A. C., Muh, C. R., & Marcus, J. R. (2017). Risk factors for delayed referral to a craniofacial specialist for Ttreatment of craniosynostosis. J Pediatr, 186, 165-171 e162. doi:10.1016/j.jpeds.2017.03.048

• Viewing – The Red Reflex Test (The Pediatric Glaucoma and Cataract Family Association – PGCFA)
• Red Reflex Examination in Neonates, Infants, and Children. (2008). Pediatrics, 122(6), 1401-1404. doi:10.1542/peds.2008-2624

ASSIGNMENT:

Each question is worth 1 point.

Case #1

The bedside nurse comes to you with a concern about a 3 week old former 32-week gestation infant who has “crusties” and some swelling of the right eye. On exam, the eye is mildly edematous, without purulent exudate or conjunctival erythema.

1. What is included in your differential diagnosis?
2. Which diagnosis is highest on it? why?
3. How would you explain the findings and plan to the parents?

Case #2

An infant is admitted to the NICU for observation and treatment after a difficult delivery requiring multiple vacuum attempts. The infant was successfully delivered via forceps. The infant required positive pressure ventilation for approximately 30 seconds and remains pale with decreased tone. Apgars are 5 and 8 at one and five minutes. The father visits the infant at one hour of age and verbalizes concern regarding the abnormal shape of the infant’s head. The head is elongated with a prominent occiput. There is pitting edema over the scalp and bruising with denuded skin over the occiput. There is a forceps mark crossing the left eye.

1. How would you approach the evaluation of this infant?
2. What is your differential diagnosis for this scalp swelling?
3. How would you explain the findings and plan to the parents?

Case #3

Baby L. was born at 36 4/7 weeks gestation, birth weight 2215 grams at 10:07 am on 10/6/2020 to a Melissa L. a 26-year-old G2P1001 by spontaneous vaginal delivery. Prenatal laboratory findings as follows: blood type O-, antibody positive, RPR non-reactive, rubella immune, HIV negative, hepatitis B negative. Rupture of membranes at 12:01 pm 10/5/2020. Maternal medications included prenatal vitamins, penicillin 1 dose, epidural, Pitocin. Routine prenatal care, pregnancy otherwise uncomplicated. Infants apgars were 6 at one minute and 8 at 5 minutes. The infant was dried, stimulated, and given CPAP +5 with 21% oxygen for persistent cyanosis.

Neonatal exam at delivery remarkable for caput, a unilateral (right side) cleft lip and palate. Clavicles intact, 3-vessel umbilical cord. Female genitalia, anus present. Moving all extremities symmetrically, 20 digits.

1. What risk factors can you identify in this H&P?
2. What other information do you want?
3. How will you explain the physical findings to the parents immediately after delivery?

Case #3

You are performing a discharge exam on a term newborn in mother/baby care. The mother asks you how can she tell if her baby can hear or not. What would you discuss with her?