From the Guidelines
Metopic ridge assessment and management should prioritize distinguishing between benign metopic ridges and true craniosynostosis, with referral to a pediatric neurosurgeon or craniofacial specialist if true craniosynostosis is suspected, as it may require surgical correction to prevent complications like increased intracranial pressure or cosmetic concerns. When evaluating a metopic ridge, key features to consider include head shape, orbital spacing, and developmental status. A normal head shape without trigonocephaly, normal orbital spacing, and absence of developmental delays are indicative of a benign metopic ridge, which typically improves with age and brain growth. However, if there are signs of intracranial hypertension, such as headache, neck pain, or papilledema, craniosynostosis should be suspected, as it can occur as early as 1 year of age and usually involves an abnormal fusion of the sagittal suture, leading to a dolichocephalic conformation of the head with a reduced cranial index 1. Some important points to consider in the assessment and management of metopic ridges include:
- Physical examination to distinguish between a normal metopic ridge and true craniosynostosis
- Imaging studies, such as skull radiographs or CT scans, to confirm the diagnosis if true metopic craniosynostosis is suspected
- Referral to a pediatric neurosurgeon or craniofacial specialist for suspected true metopic craniosynostosis
- Reassurance for parents regarding the normal nature of benign metopic ridges and their likely improvement with age
- Consideration of surgical correction for true metopic craniosynostosis, typically performed between 6-12 months of age, to prevent potential complications. It is essential to prioritize the distinction between benign metopic ridges and true craniosynostosis, as this determines whether observation or surgical intervention is appropriate, with the goal of preventing complications and improving quality of life.
From the Research
Metopic Ridge Assessment
- Metopic ridge is a midline osseous forehead prominence resulting from physiologic closure of the underlying metopic suture 2
- It can be mistaken for serious conditions such as craniosynostosis or vascular anomaly, prompting concern and workup 2
- A metopic ridge without fronto-orbital trigonocephalic deformity is the only diagnostic criterion for children with metopic ridge 3
Management of Metopic Ridge
- Radiological investigation and craniosynostosis surgery are unnecessary in children with a metopic ridge 3
- Early intervention at 3 to 4 months of age allows minimally invasive approaches for craniosynostosis repair, but requires postoperative molding helmet therapy and good family compliance 4
- Open techniques are deferred until the child is older to better tolerate the associated surgical stress 4
- A new simplified technique for surgical treatment of trigonocephaly has been developed, which is fast and easy, can provide sufficient bone graft, and is more useful for older patients (>1 year) 5
Implications for Management
- The age of the patient and severity of the head deformity are important factors in determining the appropriate management for an infant with a metopic ridge 6
- Early surgical intervention before the age of 12 months is usually recommended for metopic synostosis, which usually consists of bifrontal craniotomy with bilateral recontouring, lateral advancement, and lateral displacement of the superior orbital rims 5
- The evaluation of surgical outcomes is crucial, and the Whitaker classification can be used to scale the results 5