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This boy’s parents brought this candid photograph to show that this is the typical head posture assumed by their child.  There is no family history of such head posture, the child was the result of a normal pregancy and delivery, and is in good health now with no complaints.

1.	When first seeing this head posture, the diagnosis could be:
	g -- all of the above All, (any) of these conditions could be present with this type of head tilt.
2.	In the clinical setting, what test should be done?
	e -- all of the above All of these tests should be done.
3.	The most likely treatment would be:
	b -- appropriate surgery Just watching is not the best choice.  Neither would prisms, eye exercises or a neck brace be the best for treatment of this child.  Since this child could have any of the conditions (a) through (e), each would be most likely best treated by eye muscle surgery.  For example: (a) left medial rectus recession, (b) left inferior oblique myectomy, (c) recession left medial rectus and resection left lateral rectus, (d) right lateral rectus palsy, (e) recession of right lateral rectus and left medial rectus, (f) left superior oblique weakening.

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This case demonstrates that abnormal head posture can indicate the presence of a motility disturbance, but that a comprehensive evaluation must be carried out to arrive at the proper diagnosis.  In this question, activities are limited to the outpatient clinical setting.  In the operating room forced ductions would be carried out.

To learn more about the significance of anomalous head posture, see the Strabismus Minute, Vol. I, No. 8 and in the books “Surgical Management of Strabismus”, and “Strabismus: A Decision Making Approach”.