Vestiges of Ossified Spheno-occipital Suture in an Elderly Patient With Down Syndrome and Lateral Skull Base Fracture.

BACKGROUND/AIM: Down syndrome (DS) patients often show characteristic changes in the skull, e.g. short cranial base. The synchondroses of the skull base have a significant influence on the shape of the skull. The sphenooccipital synchondrosis (SOS) is the last of the basal synchondroses to ossify. This report is about residual ossification of SOS in an elderly patient with DS. CASE REPORT: The 65-year-old DS patient was polytraumatized by a fall. In the course of treatment, a purulent otitis externa on the right side was diagnosed, which had developed as a result of the fracture of the fossa glenoidalis. Computed tomograms of the skull base showed the fracture of the mandibular condyle, glenoid fossa and vestiges of SOS. CONCLUSION: The coincidental finding of vestiges of SOS in an elderly patient with DS raises the question of whether cross-sectional skull base images can show differences in the ossification of SOS between DS patients and a normal population.

Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury.

Although clinical signs for the diagnosis of basilar skull fracture (BSF) are ambiguous, they are widely used to make decisions on initial interventions involving trauma patients. We aimed to assess the performance of early and late (within 48 hr posttrauma) signs for BSF diagnosis and to verify the correlation between the presence of these signs and head injury severity. We conducted a prospectively designed follow-up study at a referral hospital for trauma care in Sao Paulo, Brazil, and performed structured observations for 48 hr post-blunt head injury in patients aged 12 years or older. The following signs of BSF were considered: raccoon eyes, Battle's sign, otorrhea, and rhinorrhea. Among the 136 enrolled patients (85.3% male; mean age 40 ± 21.4 years), 28 patients (20.6%) had BSF. The clinical signs for the early or late detection of BSF had low accuracy (55.9% vs. 43.4%), specificity (52.8% vs. 30.5%), and positive predictive value (25.7% vs. 27.1%). However, the presence of these signs was correlated to head injury severity, indicated by the Glasgow Coma Scale (p = .041) and Maximum Abbreviated Injury Scale-Head region (p = .002). In view of the low accuracy of these signs, resulting low clinical value of their presence, and their high sensitivity in the late stage, the study results contraindicate the value of BSF signs for making decisions about using the nasal route for the introduction of catheters and tubes in initial trauma care.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Frontobasal Fractures.

Frontobasal fractures occur in up to 24% of head injuries and often require a multidisciplinary approach. Besides the common bone fractures, the complex anatomy can cause damage to the sense of vision and smell. Further possibly lethal complications such as cerebrospinal fluid leak followed by meningitis or internal carotid bleeding can follow. Diagnostic and treatment options are reviewed with a focus on the endoscopic endonasal approach.

Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak.

OBJECTIVE: To determine rates of cerebrospinal fluid (CSF) leak, meningitis, and readmission in pediatric and adult patients with isolated basilar skull fracture. STUDY DESIGN: Cross-sectional analysis of a statewide database. SUBJECTS: Patients with isolated basilar skull fracture (1995-2010). METHODS: Patients were identified within the California Office of Statewide Health Planning and Development database using ICD-9 diagnosis codes. RESULTS: A total of 3563 pediatric and 10,761 adult patients met inclusion criteria. In-hospital rates of meningitis (0.48% and 0.64%, P = .3360) and CSF leak (2.33% and 1.75%, P = .0270) were similar among children and adults, respectively. Rates of 90-day meningitis (0.17% and 0.37%, P = .0714) and CSF leak (0.40% and 0.40%, P = .9823) were also similar. Thirty-day readmission was 4.6% for children compared with 12.4% for adults (P < .001). For both pediatric and adult patients, extra-axial hematoma (odds ratio [OR] [confidence interval {CI}] 1.65 [1.05-2.59] and 1.61 [1.34-1.95]) and comorbidities (OR [CI] 2.19 [1.11-4.34] and 1.28 [1.04-1.59]) were associated with significant increases in 30-day readmission. Loss of consciousness greater than 1 hour (OR, 3.05; 95% CI, 1.53-6.08) and CSF leak (OR, 3.28; 95% CI, 1.41-7.64) increased the likelihood of pediatric readmissions. Lack of insurance (OR, 0.67; 95% CI, 0.50-0.90) and female gender (OR 0.83; 95% CI, 0.70-0.99) reduced the likelihood of adult readmission. CONCLUSION: Meningitis and CSF leak following isolated basilar skull fractures are uncommon. Readmission within 30 days was more common in adults than in children. CSF leak, hematoma, and prolonged loss of consciousness increased the likelihood of readmission in children. Intracranial injury, male gender, having insurance, and comorbidities increased the likelihood of readmission in adults.

[Diagnosis and treatment of frontobasal cerebrospinal fluid fistulas]. / Diagnostik und Therapie von frontobasalen Liquorfisteln.

Independent of its origin a frontobasal cerebrospinal fluid (CSF) fistula is characterized by an open connection between the intracranial space with the outside world (usually the nose and paranasal sinuses). It leads to loss of CSF and is associated with a significant risk of developing meningitis for the patient during further life. Precise knowledge of possible aetiologies, clinical symptoms, current diagnostic options and surgical strategies are essential for the detection and successful management of frontobasal CSF fi fistulas. This article summarizes aetiology and clinical signs of frontobasal CSF fistulas. Further, laboratory tests to analyse fluid samples for cerebrospinal fluid as well as radiological and endoscopic investigation methods aiming to localize a CSF-fistula are presented. Finally, surgical techniques to close a frontobasal CSF fistula are explained.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures.

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.

Nonoperative treatment of occipital condyle fractures: an outcomes review of 32 fractures.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To evaluate the outcomes of patients with occipital condyle fractures (OCFs) treated nonoperatively and establish factors associated with neck disability. SUMMARY OF BACKGROUND DATA: The majority of OCFs are treated nonoperatively; however, few studies have reported long-term functional outcomes of these patients. METHODS: From 1999 to 2007, 103 patients with OCFs were identified. Of this cohort, 28 patients with 32 fractures met the inclusion criteria. Fracture and patient characteristics, including patient age and sex, Anderson and Montesano fracture type, bilaterality, associated head injury, and fracture displacement, were noted. The Neck Disability Index (NDI) was calculated at final follow-up. RESULTS: Anderson and Montesano type III fractures were the most commonly observed (54%), followed by type II (43%). The mean NDI was 14.0, which correlates with mild disability, and the NDI headache question showed the highest mean disability score of all questions. There was no statistically significant association between NDI scores and fracture type, displacement of fracture, sex, bilaterality, or presence of head injury. Age was associated with NDI scores, with age range of 40 to 60 years having a mean NDI score of 24.3. CONCLUSION: Anderson and Montessano types I, II, and III OCFs may be treated nonoperatively in the absence of ligamentous instability and concomitant cervical injuries with the expectation of mild neck disability regardless of the displacement, bilaterality, sex, or presence of head injury. Greater disability may be expected in patients aged between 40 and 60 years than in other ages.

[Diagnosis and treatment of injuries to the frontal skull base]. / Diagnostik und Therapie von Verletzungen der Frontobasis.

The role of ENT surgery in the management of anterior skull base defects has become increasingly important in recent years. Transnasal endoscopic surgical techniques and intraoperative navigation enable a minimally invasive approach in a large proportion of patients, thus helping to avoid morbidity typically associated with neurosurgical subfrontal approaches. Whereas traffic accidents and sport injuries are the main causes of anterior skull base trauma in the civilian setting, penetrating injuries caused by gunshots and improvised explosive devices (IEDs) play an increasing role in the military arena and terroristic attacks. Minor injuries to the anterior skull base are usually managed by ENT surgeons. Major injuries, involving the midface or neurocranium, require an interdisciplinary approach including maxillofacial surgeons and neurosurgeons. A centre for head and neck medicine and surgery is an ideal setting for such interdisciplinary teams to provide appropriate care for patients with complex skull base trauma in cooperation with ophthalmologists and interventional neuoradiologists. The present article describes concepts for the treatment of anterior skull base trauma established at the head, neck and skull base center at the Ulm military hospital in Germany.

[Characteristic of the upper jaw fractures combined with facial skull bone damages].

140 patients with fractures of the upper jaw have been observed regarding terms of their admission to special department in the hospital, age, sex, and reasons of damages. The ration of fractures of the upper jaw to damages of other bones of facing part of the skull and soft tissues, as well complications from it have been studied.

Combined occipital-cervical and atlantoaxial disassociation without neurologic injury: case report and review of the literature.

STUDY DESIGN: Case report and literature review. OBJECTIVE: To discuss the diagnosis, limitations, and treatment of combined occipital-cervical and atlantoaxial disassociation with normal neurologic function. SUMMARY OF BACKGROUND DATA: Injuries to the craniocervical junction can lead to devastating neurologic deficits. Occipital-cervical disassociation is a well-documented injury pattern that can lead to pain, spinal cord injury, and death. Early diagnosis and treatment can preserve neurologic function. Combined injuries to both the occipital-cervical and atlantoaxial segments are less common and, to date, have only been described with severe neurologic injury. METHODS: Retrospective review of a case. Literature review was performed through Medline and Pubmed searches. RESULTS: This is the first case to present a combined occipital-cervical and atlantoaxial disassociation with a neurologically intact patient. Initial physical examination was limited, but early imaging revealed evidence of instability. Early diagnosis and early (< 24) surgical stabilization was performed with no complications and neurologic preservation. One-year follow-up visit revealed normal neurologic examination with neck pain VAS = 2/10 and neck disability index = 6. CONCLUSION: Combined injuries to the occipital-cervical and atlantoaxial can result in upper cervical instability. Despite previous reports, neurologic preservation remains a possibility in this injury pattern. Limitations in physical examination and radiographic imaging persist, but early diagnosis and surgical stabilization may improve neurologic outcomes.

Fractura de base de cráneo en recién nacidos: caso clínico / Basal fracture of the skull in a newborn: case report and review of the literature

Introduction: Reported incidence of cranial lesions in childbirth is about 1.7 to 59 per 10,000 births. Among these, fracture of the base of the skull is rare but serious due to sequelae and mortality. Objective: Describe a case of a newborn with a fracture of the temporal bone, review diagnosis and management of skull fractures. Clinical Case: The patient was born with assistance, use of forceps, showed deviation of the buccal commisure and otorrhagia on the left side during puerperium. CT Sean detected fracture of the base of the cranium at the level of the temporal bone. Hemogram, cultures and spinal fluid studies were done. Prophylactic therapy was initiated. All blood studies were negative and follow up studies were normal. Discussion: Literature reviews support the diagnosis to be confirmed through a CT sean, and an active search for meningitis be started through hemocultures, hemogram, and Cerebrospinal Fluid. Management should be conservative, evaluating the need for an LR Evidence shows that antibiotic prophylaxis for meningitis has little indication in these cases.

Introducción: La incidencia de lesiones de cráneo en recién nacidos reportadas son del orden de 1,7 a 59 por 10 000 nacimientos. Dentro de estas, las fracturas de base de cráneo son eventos poco frecuentes, pero de consideración dado su potencial gravedad en cuanto a mortalidad y secuelas. Objetivo: Relatar el caso de un recién nacido con una fractura de peñasco y revisar el diagnóstico y manejo de las lesiones de cráneo. Caso Clínico: El paciente, tras parto instrumentalizado por fórceps, presentó desviación de comisura bucal y otorragia durante su estadía en puerperio. La TAC de cerebro con reconstrucción ósea fue compatible con una fractura de base de cráneo (peñasco izquierdo). Se tomaron hemocultivo, hemograma y PCR y se inició antibioticoterapia profiláctica para meningitis. Evolucionó favorablemente con hemocultivos negativos, hemograma y PCR normales, TAC de control sin cambios y examen neurológico normal. Discusión: La literatura recomienda que el diagnóstico de fractura de base de cráneo debe ser confirmado por medio de TAC de cerebro y que debe realizarse una búsqueda activa de meningitis por medio de hemocultivos, hemograma y PCR, evaluar la necesidad de punción lumbar y manejar en forma conservadora. La evidencia señala que la profilaxis antibiótica para meningitis en estos pacientes no tiene indicación.

William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture.

William Henry Battle (1855-1936) practiced medicine in England > 1 century ago and is primarily remembered for his description of ecchymosis over the mastoid, which indicates fracture of the skull base. Although Mr. Battle made many contributions to medicine, almost nothing exists in the literature regarding his life and findings, especially in regard to head injury. The following is a review of Battle's background and his contributions to medicine, specifically his observations associated with basilar skull fractures.