CHARGE Syndrome Clinical Presentation

Updated: Mar 25, 2022
  • Author: Megan Ehlinger Boothe, MD; Chief Editor: Maria Descartes, MD  more...
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The history in patients with CHARGE syndrome may include the following. [8, 23, 25, 26] :

Prenatal presentation

This can include the following:

  • Intrauterine growth retardation
  • Congenital heart defects
  • Orofacial clefting
  • Poor fetal movement

Neonatal presentation

This can include the following:

  • Small for gestational age
  • Dysmorphic features - Asymmetrical, square face; malar flattening; unilateral facial nerve paralysis; micrognathia; low-set, cupped ears
  • Respiratory distress/cyanosis
  • Swallowing/feeding difficulty
  • Failed newborn hearing screen
  • Inability to pass nasogastric tube

Infantile and childhood presentation

This can include the following:

  • Failure to thrive
  • Developmental delay
  • Feeding difficulty
  • Poor growth

A retrospective study by Kong and Martin found that out of 23 patients with CHARGE syndrome, 15 (65%) had at least one atopic disorder, with five (22%) having a food allergy; six (26%), a drug allergy; five, a contact allergy; two (9%), allergic rhinitis; and five, asthma. Atopic disorders did not differ significantly with regard to whether a CHD7 pathogenic variant was present. [27]



CHARGE syndrome is typically a sporadically occurring, autosomal dominant condition. Rarely, it is inherited from a parent; however, the syndrome's expression is so variable that adults may be diagnosed only after a more severely affected child has been diagnosed.

The typical defining features of CHARGE syndrome include coloboma, heart anomalies, choanal atresia, retardation of growth and development, and genital and ear anomalies. Other frequently occurring significant features include characteristic face and hand dysmorphology, hypotonia, urinary tract anomalies, anosmia, orofacial clefting, deafness, dysphagia, and tracheoesophageal anomalies. Immune deficiencies have also been reported.  [10] The occasional family member may also have features of this disease. [28]

Again, no single feature is universally present or sufficient for the diagnosis of CHARGE syndrome, and the degree of severity varies. Numerous guidelines have been published to aid in establishing a likely clinical diagnosis of CHARGE syndrome, requiring various combinations of these features. [3, 5, 6]

Coloboma of the eye (70-80%)

This is usually bilateral and affects the posterior segment of the eye (ie, choroid, retina, optic disc). It rarely involves the iris. Microphthalmia and nystagmus are consistently associated with severe coloboma. Coloboma that does not involve the fovea does not affect vision. Retinal detachment is a frequent complication. [29]

Heart anomaly (60-70%)

Septal defects (interventricular, interatrial) and conotruncal malformation (aortic valve stenosis, aortic coarctation, interrupted aortic arch) are the most frequent anomalies. Other anomalies include patent ductus arteriosus and tetralogy of Fallot. All variations of complex heart anomalies are reported.

Choanal atresia/stenosis (30-60%)

Choanal atresia is membranous or bony and bilateral in over 50% of cases, usually presenting in the newborn period with respiratory distress. Choanal atresia is a threat to life because infants cannot establish mouth breathing. A history of polyhydramnios in pregnancy is usually present. Of all features of CHARGE syndrome, choanal atresia (when bilateral) is the most easily ascertained. Its presence indicates poor prognosis for survival and necessitates multiple complex surgeries for correction. When associated with other anomalies (eg, cyanotic heart disease, tracheoesophageal fistula and/or atresia), most children with bilateral atresia do not survive beyond the first year of life. Unilateral atresia may present as persistent nasal discharge in early childhood.

Growth retardation (failure to thrive - 80%)

Intrauterine growth retardation and growth failure are observed in approximately 75% of patients. Growth failure is noticeable in the first 6 months of life. It is due to endocrine causes (eg, growth hormone deficiency, gonadotrophin deficiency). Feeding difficulty with poor caloric intake may also contribute to growth failure. No correlation between the severity of the growth defect and the severity of the component anomalies is observed.

Developmental delay and intellectual disability (70-75%)

Developmental delay is typically present and is often characterized as mild to moderate. More severe developmental delay is often associated with other significant birth defects and a greater degree of later intellectual disability.

Patients with severe coloboma and inner ear problems are particularly affected.

Poor vision and hearing result in the absence of visual and auditory cues that are essential for early motor development, and abnormalities in the vestibular function affect the adoption of upright posture and, thus, lead to delay in motor development.

The need for multiple and prolonged hospitalizations and lack of active management of the sensory deficit can also contribute to developmental delay. These issues must be adequately addressed in a timely fashion, when present, to maximize developmental outcomes.

Intellectual disability is not universal but is frequent. There is no correlation between intellectual disability and the severity of birth defects. [10]

One should be careful not to diagnose intellectual disability until the full extent of sensory deficits is known and corrective measures have been implemented.

Genital hypoplasia (male 70%, female 30%)

Males have micropenis and are either cryptorchid or have complete absence of testis. Females have labial hypoplasia that is difficult to identify in the neonatal period. Hypogonadotrophic hypogonadism secondary to pituitary or hypothalamic causes is suggested as the cause, as evidenced by poor response to luteinizing hormone-releasing hormone (LHRH) and human chorionic gonadotropin (HCG) stimulation tests.

Ear malformations (90-100%)

External ear malformation was noted in 90-100% of patients. Ears may be small, simple, low set, and/or cup shaped; protruding helix may be unraveled. External ear malformations are more abnormal on the side of the facial palsy and may be related to denervation early in the developmental process of the ear. See the image below.

Typical ear malformation Typical ear malformation

Deafness/hearing loss (60-90%)

Usually bilateral and of mixed type. A unique, wedge-shaped audiogram has been described with a descending bone conduction curve intersecting at low frequencies with a flat curve for air conduction. Inner ear abnormalities include Mondini malformation or partial or complete semicircular canal hypoplasia/aplasia. Vestibular or cochlear defect leads to sensorineural deafness. Middle ear problems cause conductive hearing loss and are commonly due to ossicular malformations, stapedius tendon abnormality, or serous effusion. CT scan of the temporal bone demonstrates partial or complete semicircular canal hypoplasia.

In a study of 12 temporal bones from six donors with CHARGE syndrome, da Costa Monsanto et al found that the highest prevalences of abnormalities impacting the ears were as follows [30] :

  • Stapes malformation - 100%
  • Aberrant course of the facial nerve - 100%
  • Aberrant course of the facial nerve with narrow facial recess - 50%
  • Sclerotic and hypodeveloped mastoids - 50%
  • Cochlear hypoplasia with aplasia of the semicircular canals - 100%
  • Vestibular hypoplasia with aplasia of the semicircular canals - 83.3%
  • Hypoplasia or aplasia of the cochlear nerve - 66.6%
  • Hypoplasia or aplasia of the vestibular nerve - 91.6%
  • Narrowing of the bony canal of the cochlear nerve - 66.6%

In addition, compared with normative data, all specimens in the study demonstrated fewer spiral and vestibular ganglion neurons. [30]

Other anomalies

These include the following:

  • Neurologic anomalies - Cranial nerve palsy (mainly facial nerve but also auditory), glossopharyngeal and vagus nerves, microcephaly, and neonatal brainstem dysfunction, which manifest in the form of feeding difficulty and swallowing difficulty, are observed

  • Cerebellar vermis hypoplasia - A study by Sohn et al found that five out of 17 patients (29.4%) with CHARGE syndrome had cerebellar vermis hypoplasia, suggesting, according to the investigators, that this may also be a sign of the syndrome; [31] in another study, Yu et al found cerebellar vermis hypoplasia in seven out of 20 of CHARGE syndrome patients (35%) proven to have a CHD7 mutation [32]

  • Dysmorphic features - These features include a typically asymmetrical, square face; malar flattening; unilateral facial nerve paralysis; and micrognathia

  • Hand dysmorphology - This includes brachydactyly and clinodactyly

  • Orofacial clefting - Cleft lip and palate is seen in approximately 30-50% of patients [33]

  • Limb anomalies - Seen in approximately one third of patients; includes hockey-stick palmar creases, square palms, hypoplastic nails, brachydactyly, syndactyly, preaxial polydactyly, and ectrodactyly; tibial aplasia has also been reported [11, 10, 34, 35]

Occasional anomalies (not consistently present)

These include the following:

  • Renal - Hydronephrosis, vesicoureteric reflux

  • Larynx - Laryngomalacia, laryngeal clefts

  • Esophageal - Atresia, tracheoesophageal fistula

  • Skeletal - Hemivertebrae, scoliosis, clinodactyly



CHARGE syndrome is an autosomal dominant condition with genotypic heterogeneity. Most cases (58-71% in unselected CHARGE referrals and as many as 90% of patients who meet criteria for typical CHARGE syndrome) are due to mutations of the CHD7 gene leading to haploinsufficiency. [1, 12, 25, 36, 28]

Microdeletions encompassing the entire CHD7 gene or affecting individual CHD7 gene exons occur in a minority of cases. [37, 38] If the CHD7 mutation analysis is normal, obtaining studies for del/dup of CHD7 and then an array of comparative genomic hybridization (CGH) are the next steps. A genotype/phenotype correlation has not been identified, although patients harboring missense variants in CHD7 less commonly fulfill the clinical criteria for CHARGE syndrome. [39]

One case report detailed CHD7 duplication, which did not result in a CHARGE-like phenotype. [40] Numerous case reports have described individuals clinically diagnosed with CHARGE syndrome who harbor various presumably pathologic cytogenetic abnormalities, including 22q11.2 deletions, 14q22-q24.3 inverted duplications, and 9p-, and single gene mutations. [13, 14, 15, 16]