What is the typical management approach for cephalohematoma?

Management of Cephalohematoma

Most cephalohematomas resolve spontaneously without intervention and should be managed conservatively with observation. Only in rare cases when complications develop should intervention be considered.

Definition and Etiology

• Cephalohematoma is a subperiosteal collection of blood above the skull, typically occurring due to birth trauma
• Distinguished from other cranial collections by its location between the periosteum and skull
• Does not cross suture lines (unlike caput succedaneum)

Natural History and Conservative Management

• Most cephalohematomas resolve spontaneously within 2-3 weeks to 1 month
• Conservative management is the standard of care for uncomplicated cases
• Regular monitoring for changes in size, consistency, or signs of infection

Indications for Intervention

Intervention is warranted only in specific circumstances:

1. Infected cephalohematoma

   • Signs include erythema, fluctuance, warmth, or systemic symptoms
   • Common pathogens include E. coli and Staphylococcal species 1
   • Management: diagnostic aspiration followed by appropriate IV antibiotics (10 days to 6 weeks)

2. Ossified cephalohematoma

   • Occurs when cephalohematoma undergoes ossification rather than resorption
   • Presents as persistent skull deformity beyond 3-6 months
   • Management: surgical correction may be indicated for significant cosmetic deformity 2, 3

3. Significant size causing pressure symptoms

   • Large cephalohematomas may rarely cause pressure symptoms
   • Management: aspiration may be considered if causing significant issues

Diagnostic Approach

• Physical examination is usually sufficient for diagnosis
• Imaging studies are indicated only for complicated cases:
  • Ultrasound: to differentiate from other fluid collections
  • CT scan: for suspected ossification or underlying skull fracture
  • MRI: rarely needed unless intracranial extension is suspected

Surgical Management

Surgical intervention is reserved for specific scenarios:

1. Infected cephalohematoma

   • Diagnostic tap for culture and sensitivity 1
   • Surgical evacuation if percutaneous aspiration fails to resolve symptoms
   • Appropriate antibiotic coverage based on culture results

2. Ossified cephalohematoma

   • Classification guides surgical approach 4:
     • Type 1 (normal inner lamella): ostectomy of outer lamella
     • Type 2 (depressed inner lamella): requires elevation of inner lamella
   • Techniques include cap radial craniectomy or flip-over bull's-eye technique 4

Complications to Monitor

• Infection (may lead to osteomyelitis, epidural abscess, or subdural empyema) 5
• Ossification causing permanent skull deformity
• Anemia (rare, in very large collections)
• Jaundice (from breakdown of blood)

Follow-up Recommendations

• Weekly monitoring until resolution for uncomplicated cases
• More frequent monitoring for large cephalohematomas
• Post-surgical follow-up at 1 week, 1 month, and 3 months

Common Pitfalls

• Misdiagnosis as caput succedaneum (which crosses suture lines)
• Unnecessary aspiration of uncomplicated cephalohematomas (increases infection risk)
• Failure to recognize signs of infection, which requires prompt intervention
• Delayed recognition of ossification, which may complicate surgical correction

Remember that while most cephalohematomas are benign and self-limiting, they can occasionally serve as a nidus for infection. Any signs of systemic infection in a neonate with cephalohematoma should prompt consideration of the collection as a potential source.