Does head tilt influence facial appearance more than head turn?

Purpose: To evaluate the frequency of facial asymmetry parameters in patients with head tilt versus those with head turn. Methods: This cross-sectional comparative study was performed on 155 cases, including 58 patients with congenital pure head turn due to Duane retraction syndrome (DRS), 33 patients with congenital pure head tilt due to upshoot in adduction or DRS, and 64 orthotropic subjects as the control group. The facial appearance was evaluated by computerized analysis of digital photographs of patients' faces. Relative facial size (the ratio of the distance between the external canthus and the corner of the lips of both face sides) and facial angle (the angular difference between a line that connects two external canthi and another line that connects the two corners of the lips) measured as quantitative facial parameters. Qualitative parameters were evaluated by the presence of one-sided face, cheek, and nostril compression; and columella deviation. Results: The facial asymmetry frequency in patients with head tilt, head turn, and orthotropic subjects was observed in 32 (97%), 50 (86.2%), and 22 (34.3%), respectively (P < 0.001). In patients with head tilt and head turn, the mean facial angle was 1.78º ± 1.01º and 1.19º ± 0.84º, respectively (P = 0.004) and the mean relative facial size was 1.027 ± 0.018 and 1.018 ± 0.014, respectively (P = 0.018). The frequencies of one-sided nostril compression, cheek compression, face compression, and columella deviation in patients with pure head tilt were found in 19 (58%), 21 (64%), 19 (58%), and 19 (58%) patients, respectively, and in patients with pure head turn the frequencies were observed in 42 (72%), 37 (63%), 27 (47%), and 43 (74%), respectively. All quantitative and qualitative facial asymmetry parameters and facial asymmetry frequencies were significantly higher in head tilt and head turn patients as compared to the control group (P < 0.001). Conclusion: All facial asymmetry parameters in patients with head tilt and head turn were significantly higher than orthotropic subjects. The quantitative parameters such as relative facial size and facial angle were significantly higher in patients with pure head tilt than pure head turn. The results revealed that pure head tilt was associated with a higher prevalence of facial asymmetry than pure head turn.

Surgical Results of Duanes Retraction Syndrome

The authors reviewed medical records of 25 patients undergoing treatment for Duanes retraction syndrome. The patients were treated with appropriate horizontal muscle recession with or without posterior fixation suture, transposition procedures, and lateral rectus Y split and recession in order to relieve face turn, significant tropia in primary position, and upshoot or downshoot. The deviation in primary position was reduced by an average or 20.5 prism diopters; 19.5 prism diopters in horizontal muscle recession with or without posterior fixation suture, and 17.4 prism diopters in lateral rectus Y split and recession. The face turn was eliminated in 84%, while 100% in horizontal muscle recession with posterior fixation suture. The upshoot or downshoot was essentially corrected by lateral rectus Y split and recession(100%). Motility of the eye was not increased following each surgical procedures. According to the results, we could obtain appropriate deviation in primary position with each surgery postoperatively. Horizontal muscle recession with posterior fixation suture was effective in eliminating the face turn. Lateral rectus muscle Y-split and recession effectively corrected upshoot and downshoots.

Surgical Treatment of the Upshoot and Downshoot in Duane's Rtraction Syndrome

The upshoot or downshoot that occurs when an eye is adducted in Duane's retraction syndrome is believed to be related to a taut lateral rectus muscle. When an eye is adducted, the lateral rectus muscle is slipped over the globe, producing this abnormal eye movement. Seven patients with Duane's retraction syndrome demonstrated this findings and underwent an Y-splitting operation on the lateral rectus muscle. Y-splitting and recession of the lateral rectus muscle is safe and simple procedure. All 7 patients demonstrated markedly decrease in the upshoot or downshoot after surgery.