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.

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.

[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 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.

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.

Positive predictive values of selected clinical signs associated with skull base fractures.

BACKGROUND: The goal of this study was to determinate the positive predictive values of selected clinical signs for skull base fractures and associated intracranial lesions. EXPERIMENTAL DESIGN: Clinical and radiological data were collected prospectively for all patients with selected clinical signs of skull base fractures, and their admission criteria were: 1) recent head injury story; 2) presence of one or more of following clinical signs: unilateral or bilateral blepharohaematoma, bloody otorrhea, and Battle's sign. SETTING: Emergency service of a institutional hospital. PATIENTS: One hundred forty two patients with the selected clinical signs for skull base fracture. RESULTS: Frontal bone fractures were the most frequent in patients with selected clinical signs. Battle's sign (100%) and unilateral blepharohaematoma (90%) were the signs with higher positive predictive values for skull base fractures; bilateral blepharohaematoma (70%) and bloody otorrhea (70%) were those with less values. The positive predictive values of the selected signs for intracranial lesions (acute extradural haematoma, pneumocephalus, brain contusion, brain sweLling, and acute subdural haematoma) were: unilateral and bilateral blepharohaematoma with positive predictive values of 85% and 68%, respectively; Battle's sign was 66%; and bloody otorrhea was 46%. For patients at admission on the 13-15 Glasgow Coma Scale only, the positive predictive values for that intracranial lesions were: blepharohaematoma=78%; Battle's sign=66%; and bloody otorrhea=41%. CONCLUSIONS: Our data demonstrated that the selected signs of skull base fractures have high positive predictive values for the presence of skull fracture and intracranial lesions, even in those patients classified in the Glasgow Coma Scale between 13 and 15. This indicates that all patients with the selected clinical signs should be submitted to computerized tomography of skull and with bone window, with the aim to detect associated lesions.

A rare clival and sellar fracture with pneumatocephalus.

We present a case of clival and sellar complex fracture produced by an indirect mechanism. This previously healthy patient had an occipital trauma followed by epistaxis. CT showed a clival and sellar fracture with pneumatocephalus. The probable fracture mechanism was contre-coup injury, linked to cerebral shock-wave transmission. This type of fracture is generally observed in the anterior part of the skull base, in a low resistance area. Severe osteoporosis probably accounted for the unusual fracture site in this patient. A mechanism of direct clival transmission is discussed, together with the usual complications of sphenoid injuries.

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.

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.

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.

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.