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
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 in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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