Facial Asymmetry and Head Tilting in Superior Oblique Palsy

ABSTRACT

We identified facial asymmetry in 81 patients with a history of long standing head tilt due to congenital or early childhood onset superior oblique palsy(SOP). To determine facial asymmetry, full frontal photographs of face were taken for each patient in a straight ahead position. They were also evaluated for skull molding, sleeping habit and degree of head tilt. Facial asymmetry was noted in 62 of 81(76.5%) patients with early onset superior oblique palsy. Eighteen of 36(50%) patients with facial asymmetry had skull molding and sleeping habit to lay down on the one side of head. Incidence of facial asymmetry was high in patients with head tilt. In addition, one of 3(33.3%) patient less than 24 months of age showed constant head tilt and facial asymmetry. After surgical correction of superior oblique palsy, head tilt was eliminated and facial asymmetry gradually disappeared. Facial asymmetry was found in 5 of 9(55.6%) patients between 2 and 3 years of age, and in 25 of 28(89.3%) patients more than 3 years of age. Fortunately it gradually improved at the long term follow-up. This study shows that the facial asymmetry cold be produced by chronic head tilt from even less than 2 years of age. Skull molding may develop in infants who prefer to sleep on one side of head. To prevent the development of facial asymmetry, early surgery less than 2 years of age may be needed. Monitoring of head position during sleep may be important to prevent skull molding. If head tilt persist even after surgical correction of SOP, secondary scoliosis, contracture of the neck muscle or habit should be considered and physical therapy may be needed.