Basilar Skull Fracture

1. Face Case #7

2. 33 YOF brought in by EMS after attending a high school baseball game, and being struck behind the right ear by a flying baseball bat while sitting in the stands. She c/o pain behind R ear, tinnitus, dizziness, and slurred speech. Denies LOC, N/V. History and Physical AFVSS Gen: WDWN, A&Ox4 HEENT: NC/AT, PERRL, EOMi , nml bilat visual acuity, bilat TMs intact , righ t hemotympanum , righ t facial motor weakness , TTP right mastoid w/o retroauricular ecchymosis Neuro : GCS-14 (Eyes 3), nml sensation x 4, 5/5 motor strength x 4

3. Image

4. Diagnosis: Basilar Skull Fracture Air in Internal Auditory Canal (thin arrow). Transverse temporal bone fracture (thick arrow). Normal suture line between temporal and occipital bones.

5. Non contrast CT head: necessary for suspected basilar skull fx . r/o TBI, intracranial bleeds +/- Prophylactic antibiotics for CSF rhinorrhea / otorrhea : should be done in consultation with Neurosurgery/ENT as most CSF leaks will resolve spontaneously in one week w/o complications if patient presents 1 wk s/p CSF leak with fever, Abx are warranted, along with meningitis work-up (LP included) Broad coverage Abx w good penetration into meninges , eg . Ceftriaxone , Vancomycin IV Tetanus prophylaxis Neurosurgery/Otolaryngology consultation ED Management

6. Signs/symptoms of Basilar Skull Fracture: Blood in ear canal Hemotympanum Rhinorrhea / Otorrhea Battle's sign ( retroauricular hematoma) Raccoon sign ( periorbital ecchymosis ) Cranial nerve deficits Facial paralysis Decreased auditory acuity Dizziness/Vertigo Tinnitus   Nystagmus Pearls

7. Most basilar skull fractures (BSF) involve petrous portion of temporal bone, external auditory canal and TM, but may occur anywhere from cribriform plate to occipital condyle . Torn dura leads to otorrhea / rhinorrhea May be only sign of basilar skull fracture Perform and document thorough HEENT exam BSF may be subtle on CT scan Look for air/fluid levels in sinuses; pneumocephalus suggests open fx Periorbital and mastoid ecchymoses develop slowly (up to 12-24 hours s/p injury), and often absent in ED. Pearls

8. Additional Images Battle’s Sign ( retroauricular ecchymosis ) Hemotympanum Raccoon’s Sign ( periorbital ecchymoses )

9. http://www.Cybermedicine2000.com Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of Emergency Medicine, 3 rd ed : http://www.accessmedicine.com Marx: Rosen’s Emergency Medicine, 7 th ed. Ch 38: Head Injury Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev . 2006 Jan 25;(1):CD004884 Schwartz DT: Emergency Radiology: Case Studies: http://www.accessemergencymedicine.com Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7 th ed. Chapter 254: Head Trauma in Adults and Children References