Base of Skull Fracture
OVERVIEW
- fracture involving the floor of the cranial vault
CLINICAL FINDINGS
- Periorbital ecchymosis (raccoon eyes)
- CSF rhinorrhoea
- CSF otorrhoea
- Haematotympanum
- mastoid ecchymosis (Battle sign)
- VIIth (facial paralysis) and VIIIth (hearing loss) CN dysfunction
COMPLICATIONS
- Pneumocephalus from mask ventilation
- Inadvertent intracranial tube placement (nasogastric or nasal intubation)
- Carotid artery damage: dissection, pseudoaneurysm, thrombosis
- Carotido-cavernous fistula (e.g. pulsating exophthalmus, orbital bruit)
- Caverous sinus thrombosis
- CSF fistula (within 1 week)
- Basal meningitis
- Panhypopituitism
MANAGEMENT
Specific therapy
- TBI management (nicluding ICP control)
- seek and treat complications
- elevation of depressed skull fractures
- CSF leak management
CSF leak
- risk of meningitis from direct contact of CSF to sinus, nasopharynx or middle ear
- few RCTs exist
- no role for prophylactic antibiotics (doesn’t reduce the risk of meningitis)
- frequent cultures of leaking or draining CSF should be taken (send for B2 transferin) and infections treated specifically
- can prescribe antibiotics to cover insertion of ICP monitor
- most CSF leaks are conservatively managed
- persistent leaks >7 days have heightened risk of meningitis and are often surgically repaired
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
LITFL
- Eponymictionary – Battle Sign
- Eponymictionary – William Henry Battle (1855-1936)
Journals
- Abuabara A. Cerebrospinal fluid rhinorrhoea: diagnosis and management. Med Oral Patol Oral Cir Bucal. 2007 Sep 1;12(5):E397-400. Review. PubMed PMID: 17767107.
- Gray ST, Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma. 2003 May;54(5):1026-34. Review. PubMed PMID: 12777923.
- Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD004884. doi: 10.1002/14651858.CD004884.pub3. Review. PubMed PMID: 21833952.
- Wu AW. Pathophysiology of iatrogenic and traumatic skull base injury. Adv Otorhinolaryngol. 2013;74:12-23. doi: 10.1159/000342264. Epub 2012 Dec 18. Review. PubMed PMID: 23257548.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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