The Head Exam

August 23, 2007

Some have suggested that  I  get my head examined. 

As hard as I looked, I could not find a good phrenologist anywhere.  I was actually encouraged that I could not find any "alternative medicine" sites that suggested phrenology had merit (there is a web page called "Phrenology for Fun and Profit" that is a punk rock website).  I guess goofiness has its limits.

On 99% of physical exams by physicians, if you see a head exam, it will look something like this:  Head:  NC/AT.  NC/AT stands for Normocephalic, Atraumatic.

Does Size Matter?

The term normocephalic means that the head is normal in shape and size.  When examining infants we are interested mostly in the size of the head, although the shape is important as well.  When children come in for a well-check, we measure the head size up until 2 years of age.  The goal of this measurement is to determine whether the child is developing macrocephaly or microcephaly. 

Macrocephaly means big head.  It is actually normal for infants to have a large head relative to their body, but a head growing too much can indicate a serious problem: namely hydrocephalus.  Hydrocephalus is a condition where the pressure of the fluid that surrounds the brain (CSF) is too high.  This can cause significant problems if undiagnosed (although I have to say that I have yet to diagnose a case of it, so it is quite rare).

Usually a big head is simply from heredity.  My family all have big heads.  When I see a child with a large head that is growing at a normal rate, I will joke with the parents that the child has a big head, probably due to everyone saying how cute they are.  Interestingly, there is a scientific basis to this.  The ethnologist Konrad Lorenz studied what makes something cute across cultures.  He found:

we are drawn to relatively large heads, large and low-lying eyes, bulging cheeks, short and thick arms and legs, springy elastic skin, and clumsy movements.  (Taken from a very good article in FirstScience)

This explains why people would do the incredibly foolish act of buying Precious Moments figurines.  We all know that it has been well documented that these creatures are the minions of Satan.

So are kids with bigger heads smarter than their microcephalic counterparts?  No, although a drop in percentiles in head size can indicate certain genetic syndromes which are associated with small head.

Head Shape

One of the great sources of anxiety for many new parents is the "soft spot" or fontanel at the top of the child’s head.  There are actually two fontanels, anterior and posterior, on a child’s head, but the anterior fontanel is the one that is most visible.  The fear of many parents is that touching the fontanel can cause brain damage.  This is not the case, and there is absolutely no problem if you touch or push on your child’s fontanel. 

Another source of anxiety among parents is the "sunken fontanel."  When a child becomes dehydrated, the fontanel does become much less prominent and the depression becomes deeper.  I find this, however, quite unreliable, and have had to reassure many parents of healthy children that an isolated sunken fontanel is not a sign of any problems.  The depth of the fontanel on the head is related to the pressure of the CSF and will vary depending on the position of the head.

Finally, there is the creepy pulsating that parents sometimes see of the fontanel.  While this looks like something out of a sci-fi movie, it is normal as well.

When I examine a child’s fontanel, I am looking for a premature closure of the sutures (the groove that separate the skull bones).  This can cause a condition known as craniosynostosis,  in which a child’s head grows to a very abnormal shape, as it does not grow along sutures that have closed.  Children with craniosynostosis who have not been treated, while normal in intelligence, have very odd shaped heads.  I have diagnosed this several times in my practice, and the surgical intervention for it thankfully results in a very normal looking child.

Head Cases

Most of the time, examination of the head is done in passing.  If I don’t notice something obviously wrong, I note "NC/AT" in the chart and move on.  There are problems specific to the head, however, that do come up often in my daily routine.

Lice

Head lice are the bane of daycare centers and schools, and will close down an exam room for thorough cleaning and inspection.  The symptom of head lice is itchy scalp and the exam involves looking for both the small insects on the scalp and the nits on the hair (the eggs of the insect).  It is fairly common in children, and is easily treated with several topical medications.

One time I diagnosed a child with lice and my nurse told me later that I had "made the entire trailer park where the child lives go crazy over getting rid of lice."

Hairloss

I once heard the following:

Men who are bald in the front are thinkers.

Men who are bald in the back are sexy.

Men who are bald in the front and the back think they’re sexy.

I am proud to say that I am balding in the back of my head.  Sorry, I am already taken.

Male-pattern balding is caused by both genetic and hormonal factors.  The hormone most commonly related to baldness is dihydroxytestosterone (DHT), which is at lower levels in men with baldness.

Women come in with complaint of hairloss on a regular basis.  The most common cause of hairloss in women is something known as Telogen Effluvium. 

Telogen Effluvium is characterized by sudden, diffuse hair loss caused by an interruption in the normal hair growth cycle. This interruption is often the result of trauma, such as chemotherapy, childbirth, puberty, major surgery, severe stress, and severe chronic illness. This trauma causes large numbers of hair follicles to enter a stage of telogen, or rest, simultaneously. After roughly 3 months of the telogen cycle the follicles will enter the anagen cycle, a stage of growth. The old hair will be forced out of the follicle by a new hair that is formed beneath it. This will cause a period of diffuse hair shedding. This condition is usually self correcting and can affect people of all ages. There is also another form of Telogen Effluvium referred to as ‘Chronic’. This is essentially the same except it is on-going.

A typical example of telogen effluvium is seen after pregnancy. In this condition women lose a significant amount of hair a few months after delivery when the protective effect of estrogen is removed. This shedding usually stops spontaneously and these patients will re-grow hair after 3 months.

So if someone tells you that you should have your head examined, you should explain to them that the head exam, while occasionally significant, is usually fairly low-yield for doctors.  Reassure them that you are probably NC/AT.

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Posted in Physical Exam