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Updated: Oct 20 2021

Basilar Skull Fracture

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  • 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
        • distinguishing features
          • proptosis
          • blurry vision
          • pain with extraocular movements
          • elevated intraocular pressure
  • 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)
        • carotid injury
        • CN VII and/or CN VIII injury
        • mastoid cerebrospinal fluid (CSF) leak
      • anterior skull base fractures
        • orbital injury
        • nasal CSF leak
        • CN I injury
      • central skull base fractures
        • carotid injury
        • CN III, IV, V, and/or VI injury
      • posterior skull fractures
        • cervical spina injury
        • vertebral artery injury
        • CN IX, X, and XII injury
  • Presentation
    • Symptoms
      • altered mental status
      • nausea
      • vomiting
    • Physical exam
      • cranial nerve deficits (depending where the fracture occured)
      • hemotympanum
        • blood pooling behind the tympanic membrane
      • CSF rhinorrhea or otorrhea
      • periorbital ecchymosis (raccoon eyes)
        • associated with anterior skull base fractures
      • retroaurticular or mastoid ecchymosis (Battle sign)
  • Imaging
    • Noncontrast head CT
      • indication
        • initial imaging study for patients with head trauma
      • findings
        • skull fractures
          • difficult to assess if the fracture is linear or non-displaced
  • 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
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