1. Quality Education for a Healthier Scotland Multidisciplinary “ Your face, my thane is as a book …” Macbeth Promoting multiprofessional education and development in Scottish maternity care

2. Quality Education for a Healthier Scotland Multidisciplinary Objective: to detect the commonest abnormalities of the face eye ear and hearing mouth to review their significance in the newborn and refer appropriately.

3. Quality Education for a Healthier Scotland Multidisciplinary Structure of the talk Face size vs Head Symmetry and Position Abnormal Eyes Abnormal Ears Nose and Lips Abnormal Mouth Abnormal Palate. The Face

4. Quality Education for a Healthier Scotland Multidisciplinary The Face: Whole Picture

5. Quality Education for a Healthier Scotland Multidisciplinary Symmetry and Position Facial Palsy: Commoner after forceps delivery Compression effect of the forceps on the branch of the facial nerve is often transient, and total recovery is usually anticipated Look for other injuries.

6. Quality Education for a Healthier Scotland Multidisciplinary Symmetry and Position Asymmetric crying faces: Congenital lack of normal innervation to mid face Association with cardiac disease.

7. Quality Education for a Healthier Scotland Multidisciplinary The Face: Trauma Petechiae and bruising Congestion common in face to pubes presentation This bruising from bleeding under deep layers of scalp.

8. Quality Education for a Healthier Scotland Multidisciplinary The Eye Normal Lids Overall size Symmetry/position Round iris Pupil/lens Red light reflex/retina. Normal eye

9. Quality Education for a Healthier Scotland Multidisciplinary The Eyelids Swelling from delivery Bruising Sub-aponeurotic Infection.

10. Quality Education for a Healthier Scotland Multidisciplinary The Eye Coloboma: Is a defect in the closing of the globe Ranges in severity from a notch in the lower part of the iris, making the pupil pear–shaped, to defects behind the iris in the fundus.

11. Quality Education for a Healthier Scotland Multidisciplinary The Eye With your ophthalmoscope set to +3 dioptres examine the cornea, iris and red reflex from a distance of approx 20 cm.

12. Quality Education for a Healthier Scotland Multidisciplinary Red reflex An abnormal red reflex requires an urgent ophthalmologic opinion as it may represent a cataract or a mass of abnormal tissue.

13. Quality Education for a Healthier Scotland Multidisciplinary The White Eye/Leukocoria Cataract The lens does not allow light through to illuminate the retina May be tiny central dots. Familial e.g. Galactokinase deficiency. retinoblastoma Retinoblastoma

14. Quality Education for a Healthier Scotland Multidisciplinary The White Eye Primary persistent vitreous The solid tissue which formed the globe of the eye has persisted leaving permanent blindness and glaucoma.

15. Quality Education for a Healthier Scotland Multidisciplinary The Eye Congenital glaucoma Obstruction to outflow of fluid from the eye Large hazy eye.

16. Quality Education for a Healthier Scotland Multidisciplinary The Eye Blocked Lacrimal Duct Resolve <12 months >12 months refer to ophthalmologist for possible probing.

17. Quality Education for a Healthier Scotland Multidisciplinary Dacrocystoceles

18. Quality Education for a Healthier Scotland Multidisciplinary Squashed nose

19. Quality Education for a Healthier Scotland Multidisciplinary The Nose Choanal Atresia: This can be one or both sides, bony or membranous Usually presents with cyanosis when not crying.

20. Quality Education for a Healthier Scotland Multidisciplinary The Nose Snuffles Noses can be partially blocked by vernix, blood, milk, etc. Later low grade bacterial sepsis can be a problem.

21. Quality Education for a Healthier Scotland Multidisciplinary The Ear Size Shape Position Abnormalities Extra bits.

22. Quality Education for a Healthier Scotland Multidisciplinary The Ear Position Low set Normal

23. Quality Education for a Healthier Scotland Multidisciplinary Low Set Ears

24. Quality Education for a Healthier Scotland Multidisciplinary The Ear Shape Branchial arch anomalies with unusual ears, small mandibles Oto-renal syndromes with unusual ears, fistulae in neck and renal problems.

25. Quality Education for a Healthier Scotland Multidisciplinary The Ear Size Trisomy 18 with small abnormal and low set ears Potter’ syndrome: Renal problems leading to oligohydramnios and a squashed baby.

26. Quality Education for a Healthier Scotland Multidisciplinary Ear position and shape As in CHARGE syndrome.

27. Quality Education for a Healthier Scotland Multidisciplinary The Ear Pre-auricular pits or small fistulae. This baby’s mother had a similar pit but on the other side. There were no associated problems in this case.

28. Quality Education for a Healthier Scotland Multidisciplinary The Ear Skin tags Simple tags are usually only cosmetic. Multiple or large tags can indicate hearing abnormalities or syndromes. Formal excision is usually recommended.

29. Quality Education for a Healthier Scotland Multidisciplinary The Mouth Gums Tongue Palate Hard Soft.

30. Quality Education for a Healthier Scotland Multidisciplinary Tongue tie Common Not usually divided unless interfering with feeding Possible late association with speech problems.

31. Quality Education for a Healthier Scotland Multidisciplinary Ranulae Mucous inclusion cysts in the sublingual salivary glands on the floor of the infants mouth. They are usually small and will spontaneously regress. Larger ones need surgical removal.

32. Quality Education for a Healthier Scotland Multidisciplinary Epstein's Pearls Nodules of epithelial cells resembling pearls just lateral to the midline on the hard palate (with a cluster at the junction of the hard and soft palate) are a normal finding.

33. Quality Education for a Healthier Scotland Multidisciplinary Neonatal teeth Usually superficial in the gum and are removed to avoid maternal nipple problems.

34. Quality Education for a Healthier Scotland Multidisciplinary The Mouth

35. Quality Education for a Healthier Scotland Multidisciplinary Cleft Lip and or palate = 1 / 700 births 53% Isolated Cleft Soft (2°) Palate Cleft palate 80% Isolated deformity Familial 12% Syndromic 8% Affected sib = x 3.5 Two sibs = x 13.

36. Quality Education for a Healthier Scotland Multidisciplinary Cleft Palate High Risk Family History Maternal exposure to teratrogens incl. Anti-convulsants, steroids, alcohol Syndromes, e.g.Trisomy13,18 Infant of diabetic mother (Χ2) Milk coming down nose during feeds.

37. Quality Education for a Healthier Scotland Multidisciplinary Cleft palate

38. Quality Education for a Healthier Scotland Multidisciplinary Cleft palate

39. Quality Education for a Healthier Scotland Multidisciplinary Cleft uvula A small posterior cleft palate is often missed. The bifid uvula seen here points towards a sub mucous cleft.

40. Quality Education for a Healthier Scotland Multidisciplinary Cleft lip and palate Unilateral.

41. Quality Education for a Healthier Scotland Multidisciplinary Cleft lip and palate Bilateral.

42. Quality Education for a Healthier Scotland Multidisciplinary Cleft Palate - Examination Spontaneous visualisation best Palpation with little finger of hard and soft palate Visualisation during gag HIGH RISK group only - use laryngoscope.

43. Quality Education for a Healthier Scotland Multidisciplinary Any questions?

44. Quality Education for a Healthier Scotland Multidisciplinary Summary Follow your instincts about a funny-looking face, but it may be familial! One abnormality may follow another – remember associations esp. hearing. If there is an increased risk of a cleft palate – formally view the soft palate. Kind thanks to Janelle Aby, MD for many of the photographs