Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience

We read with interest the article entitled “Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience,” by Ulma et al.1 This retrospective study is based on 72 patients with calcified cephalohematoma and the surgical management of 30 of them. This is the first large cohort in the literature to precisely inform readers about patients’ characteristics and the operative technique and surgical complications of this procedure in infants with a mean age at surgery of 8.6 months. No revision surgery was necessary. Seventy percent of patients required inlay bone grafting. The improvement in calvarial shape was reported to be significant, although the mean follow-up was only 7 months in the operative group and 3.7 months in the nonoperative group. Moreover, to better evaluate the effect of the surgical procedure, we should expect precise data, such as deformity size or results of a familial satisfaction questionnaire before and after surgery. The authors did not find any significant differences in demographics, characteristics, and risk factors between the operative and nonoperative groups, mostly because the final decision of surgical intervention was based on familial concern. For aesthetic correction of calcified cephalohematoma, the authors propose the surgical treatment rather than observation, orthotic helmet, or needle aspiration. However, with regard to the latter, the authors based their rationale on insufficient data. Needle aspiration under local anesthesia could be a safe and efficient treatment for a large, unaesthetic cephalohematoma if it is carried out before 4 weeks. This early intervention allows for drainage of the hematoma before its calcification and should prevent occurrence of skull deformity. This procedure does not expose the patient to the risks of general anesthesia,2 transfusion (26.7 percent), subgaleal hematoma (6.7 percent), wound infection (6.7 percent), and irradiation from the preoperative computed tomographic scan in the treatment proposed by Ulma and colleagues. The risk of infection of the cephalohematoma related to the needle aspiration, as mentioned in the article, is not supported by the literature. The only article cited was about 26 infected cephalohematomas,3 but only one patient underwent needle aspiration. Most of the other cases were secondary to systemic infection or were not a consequence of scalp erosion. Moreover, at our institution, a published retrospective study of 67 newborns with cephalohematoma, treated by needle aspiration, showed that the infectious risk was theoretically null if the condition of strict asepsis was fulfilled.4 Needle aspiration under local anesthesia of large, unaesthetic cephalohematoma, between 2 and 4 weeks of age, after coagulation evaluation and ultrasound of the skull and scalp, may prevent the apparition of calcified cephalohematoma requiring more risky delayed surgical treatment. Following this algorithm (Fig. 1) at our center for 20 years, surgery has not been required for any unaesthetic calcified cephalohematoma. Surgery could be proposed for unsatisfactory results of needle aspiration and for patients already presenting with a calcified cephalohematoma at diagnosis.Fig. 1.: Algorithm for initial treatment of cephalohematoma in the newborn.Ulma and colleagues provide important data on surgical treatment of calcified cephalohematoma of patients under 1 year of age, in the largest cohort published to date. Early needle aspiration under local anesthesia is a valid option to treat large unaesthetic cephalohematoma, preventing later calcification and persistent skull deformity. This procedure can be safely proposed and should be discussed with the parents, as indicated in the treatment algorithm for this condition. Fabian Blanc, M.Sc.Pediatric Orthopedic Plastic Surgery UnitMontpellier University HospitalUniversity of MontpellierLapeyronie Hospital Guillaume Captier, M.D., Ph.D.Pediatric Orthopedic Plastic Surgery UnitMontpellier University HospitalUniversity of MontpellierLapeyronie HospitalMontpellier, France