Snapshot A 45-year-old man is brought to the emergency department after being found down in the park. The patient reports that he was physically assaulted by a group of men. Since then he reports episodes of rhinorrhea and occasional leakage from the ear. Physical examination is notable for periorbital and retroaurticular ecchymosis without evidence of a CSF leak. Non-contrast head CT demonstrates a basilar skull fracture but with no evidence of an intracranial hemorrhage. Neurosurgery was consulted, who recommended no surgical intervention but to be admitted for frequent neurological assessments. Introduction Definition breaking of bone at the base of the skull Associated conditions cervical spine injury retrobulbar hematoma login to view 5 more bullets Etiology high-velocity blunt trauma (e.g., motor vehicle collisions and pedestrian injuries) penetrating injuries (e.g., gunshot) Pathogenesis the location of the fracture predicts injury temporal fractures (most common) login to view 3 more bullets anterior skull base fractures login to view 3 more bullets central skull base fractures login to view 2 more bullets posterior skull fractures login to view 3 more bullets Presentation Symptoms altered mental status nausea vomiting Physical exam cranial nerve deficits (depending where the fracture occured) hemotympanum login to view 1 more bullet CSF rhinorrhea or otorrhea periorbital ecchymosis (raccoon eyes) login to view 1 more bullet retroaurticular or mastoid ecchymosis (Battle sign) Imaging Noncontrast head CT indication login to view 1 more bullet findings login to view 2 more bullets Studies Making the diagnosis this is a clinical diagnosis supported by head imaging Treatment Managed expectantly required urgent neurosurgical evaluation and frequent neurology checks Complications Meningitis CSF leak Cranial nerve palsies Cavernous sinus thrombosis