Anatomy, Head and Neck, Fontanelles


Article Author:
Brody Lipsett


Article Editor:
Kim Steanson


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/9/2019 11:37:42 AM

Introduction

At birth, the newborn’s skull consists of five major bones (two frontal, two parietal, and one occipital) that are separated by connective tissue junctions known as cranial sutures.[1] The sutures function as seams, and they are highly necessary to facilitate the movement and molding of the cranium through the birth canal during labor. They also allow for rapid postnatal growth and development of the brain. However, the bones that shape the cranium begin unfused, leaving several gaps between the individual bones of the infant's skull. These gaps are composed of membranous connective tissue and are known as fontanelles.

Fontanelles often referred to as “soft spots,” are one of the most prominent anatomical features of the newborn’s skull. Six fontanelles are present during infancy, with the most notable being the anterior and posterior fontanelles. Fontanelle morphology may vary between infants, but characteristically they are flat and firm. Certain conditions such as dehydration or infection can alter the appearance of the fontanelles, causing them to sink or bulge, respectively. This article will review the anatomical location and structures that border the fontanelles and their average closure time. Additionally, this article will cover proper examination techniques, medical imaging, and medical conditions that most commonly affect fontanelle morphology.

Structure and Function

Anterior Fontanelle

The anterior fontanelle is the largest of the six fontanelles, and it resembles a diamond-shape ranging in size from 0.6 cm to 3.6 cm with a mean of 2.1 cm.[2]  It forms through the juxtaposition of the frontal bones and parietal bones with the superior sagittal sinus coursing beneath it. Two frontal bones join to form one-half the anterior fontanelle with the metopic suture serving as the parallel divider between the paired bones. Next, the parietal bones are positioned against each other to complete the fontanelle. The positioning of the two parietal bones against each other gives rise to the sagittal suture. Finally, the alignment of the frontal bones against the parietal bones establishes the coronal suture.

The average closure time of the anterior fontanelle ranges from 13 to 24 months.[3] Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will closer sooner compared to female infants.[4][5] The most common conditions associated with a large anterior fontanelle or a delay in its closure are as listed: Down syndrome, achondroplasia, congenital hypothyroidism, rickets, and elevated intracranial pressures.[6] An extensive list of conditions associated with these findings will follow in the clinical significance section of this article.

In addition to being the largest, the anterior fontanelle is also the most important clinically.[7] This structure offers insight into the newborn’s state of health, especially hydration and intracranial pressure status. A sunken fontanelle is primarily due to dehydration. Other clinical indicators that support the diagnosis of dehydration are dry mucous membranes, sunken eyes, poor tear production, decreased peripheral perfusion, and lack of wet diapers.[8] Furthermore, a bulging fontanelle may indicate a rise in intracranial pressure, suggesting multiple pathologies: hydrocephalus, hypoxemia, meningitis, trauma, or hemorrhage. The clinical significance section will highlight an extensive but not complete list of differential diagnoses of a bulging anterior fontanelle.

Posterior Fontanelle

Unlike the anterior fontanelle, the posterior fontanelle is triangular and completely closes within about six to eight weeks after birth.[7] This structure arises from the juncture of the parietal lobes and occipital lobe. Through this placement, the lambdoid suture forms. On average, the posterior fontanelle is 0.5 cm in Caucasian infants and 0.7 cm infants of African descent.[4] Often, the delayed closure of the posterior fontanelle is associated with hydrocephalus or congenital hypothyroidism.[9]

Mastoid Fontanelle

The mastoid fontanelle, a paired structure, can be found at the intersection of temporal, parietal, and occipital bones. Additionally, the mastoid fontanelle also has the name of the posterolateral fontanelle. These fontanelles may close anywhere from six to eighteen months of age.

Sphenoid Fontanelle

Similarly, the sphenoid fontanelle is also a paired fontanelle. Its location can be on either side of the skull at the convergence of the sphenoid, parietal, temporal, and frontal bone. It is also known as the anterolateral fontanelle. Their closure occurs at approximately the sixth-month mark after birth.

Third Fontanel

Uniquely, a third fontanelle between the anterior and posterior fontanelles correlates with certain conditions like Down syndrome and congenital infections such as rubella. The frequency of this third fontanelle has been reported to be 6.4% in an unselected population of 1020 newborns.[10]

Embryology

As the growth and development of the newborn continue, each fontanelle will close within their respective timelines by a process known as intramembranous ossification. The flat bones of the cranium are considered the membranous portion of the neurocranium that consists of mesenchyme. The mesenchyme undergoes a process in which bony needle-like projections called spicules radiate from primary ossification centers towards the periphery. As the infant continues to mature, appositional growth ensues by osteoblasts providing new layers of bone to the outer portion of the cranial bones while osteoclasts resorb the inner framework simultaneously.[7]

Surgical Considerations

Depending upon the specific pathology affecting the anterior fontanelle, surgical intervention may be necessary. For example, an infant with the diagnosis of craniosynostosis (premature cranial suture closure) will have an increase in intracranial pressure which can lead to devastating brain injury or can even be lethal. Surgical intervention for this specific condition is treated by either a craniotomy or craniectomy, taking special consideration to avoid iatrogenic injury to the superior sagittal sinus.[3] The exact procedure utilized is a decision made on a case-by-case basis. 

Clinical Significance

As with any clinical encounter, it is essential to gather a detailed history and perform a thorough physical examination. These two aspects of the encounter will be integrated to determine a proper diagnosis and subsequent management for the patient. A newborn’s birth history may be unremarkable; thus, the physical examination will be of greater significance.  Each component of the physical exam: observation, palpation, percussion, and auscultation can yield important findings. Observation of the infant’s skull should be performed first during the physical examination. It should be evaluated for its morphology including size and shape as well as its circumference and related sutures, noting any abnormalities. Many conditions are associated with a large anterior fontanelle or a delay in its closure[6]:

  • Most Common
    • Achondroplasia
    • Congenital hypothyroidism 
    • Down syndrome
    • Increased intracranial pressure
    • Rickets
  • Less Common
    • Osteogenesis imperfecta
    • Hypophosphatasia
    • Trisomy 13
    • Trisomy 18
    • Congenital rubella
    • Syphilis
    • Amphoterin-induced malformation
    • Fetal hydantoin
    • Beckwith-Wiedemann syndrome
    • Zellweger syndrome
    • VATER Association
    • Malnutrition 
    • Hydranencephaly
    • Intrauterine growth retardation

Next, the anterior and posterior fontanelles merit special attention, documenting their size and shape by direct observation and palpation.  Best results are achieveda when the infant is pleasant and agreeable, as the fontanelle can appear to be bulging or full in an angry or crying infant.  The infant should also be examined in both the supine and upright positions. A normal soft pulsation may be palpated at the anterior fontanelle. If the fontanelle feels tense and protuberant, it may be an indication of underlying pathology. Palpation of a bulging fontanelle is often equated to palpating an osseous structure. Several medical conditions that are associated with a bulging fontanelle are the following categorized by organ systems: 

  • Neurological
    • Hydrocephalus, brain tumors, intracranial hemorrhage
  • Cardiovascular
    • Congestive heart failure, dural sinus thrombosis
  •  Hematologic
    • Polycythemia, anemia, leukemia
  • Infectious
    • Meningitis, encephalitis, roseola, shigella, mononucleosis, poliomyelitis, abscess 
  • Endocrine
    • Hyperthyroidism, hypothyroidism, hypoparathyroidism, pseudohypoparathyroidism
  • Metabolic
    • Diabetic ketoacidosis, electrolyte abnormalities, uremia, galactosemia, hypophosphatasia, osteoporosis
  • Miscellaneous
    • Trauma, hypoxemia, dermoid cysts, lead encephalopathy, aluminum toxicity, hypervitaminosis A, coronal synostosis

During the physical examination of the infant with increased intracranial pressure, the percussion of the fontanelle may produce a dull acoustic note that lacks resonance; this is Macewen sign. Macewen sign is an auditory sign that resembles the sound of percussing a cracked pot when the examiner percusses the fontanelle; hence it was also termed the “cracked pot” sign.[11] However, it is worth noting that excessive crying may also produce a bulging fontanelle. Thus, it is important to use clinical judgment before providing a definitive diagnosis.   Auscultation of the fontanelles may reveal a bruit, especially in infants with heart failure or multiple hemangiomas. The detection of a bruit in newborns may suggest an arteriovenous malformation and further workup is warranted. If medical imaging is necessary, ultrasound is the modality of choice to visualize ventricular structures, while neoplasms are best diagnosed with an MRI.[12][13]

Other Issues

As a healthcare professional tasked with the care of newborns or infants, an understanding of normal fontanelle morphology, variations, and average closure timelines is essential. Many medical conditions can affect fontanelle morphology and may be life-threatening. A complete history and physical examination with particular attention to the analysis of the fontanelles can provide valuable insight into the infant’s health status and assist in formulating an appropriate differential diagnosis. If uncertainty arises, it is imperative to consult the pediatric neurosurgery team to be involved in the infant’s care.


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    Contributed by Gray Plates 197 & 198
Attributed To: Contributed by Gray Plates 197 & 198

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Anatomy, Head and Neck, Fontanelles - Questions

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The structure at the convergence of the lambdoid and occipital sutures is no longer palpable on an infant's head during which time period?



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A father makes an appointment with his healthcare provider because he is concerned about several soft spots on his 3 week-old newborn son's head. He is very worried that something is wrong with his son. The healthcare provider calmly reassures the father that these are fontanelles and that they are normal anatomical structures during infancy. He provides the appropriate education and reassures the father that they will close over different times during development. The fontanelle located at the junction of the sagittal, coronal and frontal suture lines usually closes by which age during infancy?



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The anterior fontanelle of an infant is located at the junction of which of the following bones?



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Anatomy, Head and Neck, Fontanelles - References

References

Chemke J,Robinson A, The third fontanelle. The Journal of pediatrics. 1969 Oct;     [PubMed]
Adeyemo AA,Omotade OO, Variation in fontanelle size with gestational age. Early human development. 1999 Apr;     [PubMed]
Popich GA,Smith DW, Fontanels: range of normal size. The Journal of pediatrics. 1972 May;     [PubMed]
Faix RG, Fontanelle size in black and white term newborn infants. The Journal of pediatrics. 1982 Feb;     [PubMed]
Duc G,Largo RH, Anterior fontanel: size and closure in term and preterm infants. Pediatrics. 1986 Nov;     [PubMed]
Rothman SM,Lee BC, What bulges under a bulging fontanel? Archives of pediatrics     [PubMed]
Kiesler J,Ricer R, The abnormal fontanel. American family physician. 2003 Jun 15;     [PubMed]
D'Antoni AV,Donaldson OI,Schmidt C,Macchi V,De Caro R,Oskouian RJ,Loukas M,Shane Tubbs R, A comprehensive review of the anterior fontanelle: embryology, anatomy, and clinical considerations. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2017 Jun;     [PubMed]
Alexander E Jr,Davis CH, Macewen's sign--     [PubMed]
Ruge JR,Tomita T,Naidich TP,Hahn YS,McLone DG, Scalp and calvarial masses of infants and children. Neurosurgery. 1988 Jun;     [PubMed]
Machado HR,Martelli N,Assirati Júnior JA,Colli BO, Infantile hydrocephalus: brain sonography as an effective tool for diagnosis and follow-up. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 1991 Aug;     [PubMed]
Mackenzie A,Shann F,Barnes G, Clinical signs of dehydration in children. Lancet (London, England). 1989 Dec 23-30;     [PubMed]
Esmaeili M,Esmaeili M,Ghane Sharbaf F,Bokharaie S, Fontanel Size from Birth to 24 Months of Age in Iranian Children. Iranian journal of child neurology. 2015 Fall;     [PubMed]

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