From the Guidelines
Battle sign, a bruise behind the ear over the mastoid process, is a clinical indicator of a basal skull fracture that typically appears 24-48 hours after injury, and its management should prioritize immediate stabilization and diagnostic confirmation with a non-contrast CT scan of the head and cervical spine, as indicated by the Canadian CT Head Rule 1.
Management and Diagnosis
The management of a patient presenting with Battle sign involves:
- Immediate stabilization following ATLS protocols, securing the airway while maintaining cervical spine immobilization, ensuring adequate breathing and circulation, and performing a thorough neurological assessment.
- Diagnosis requires a non-contrast CT scan of the head and cervical spine to confirm the fracture and identify associated injuries like intracranial hemorrhage or cervical spine trauma, as the Canadian CT Head Rule suggests that a sign of basal skull fracture is one of the high-risk factors that necessitate CT imaging 1.
- Patients should be admitted for close neurological monitoring, with neurosurgical consultation for all cases.
Treatment
Treatment is primarily supportive, including:
- Head elevation to 30 degrees.
- Pain management with acetaminophen (avoiding NSAIDs due to bleeding risk).
- Seizure prophylaxis with levetiracetam 500-1000 mg twice daily for 7 days if there's intracranial bleeding.
- CSF leaks, indicated by clear rhinorrhea or otorrhea, require head elevation and may need prophylactic antibiotics like ceftriaxone 2g IV daily if persistent beyond 7 days.
Complications and Recovery
- Surgical intervention is rarely needed unless there are complications such as significant intracranial hemorrhage or persistent CSF leak.
- Patients should be counseled to avoid activities that increase intracranial pressure, such as straining or heavy lifting, for 4-6 weeks during recovery, as recommended by general clinical guidelines for managing basal skull fractures 1.
From the Research
Diagnosis of Battle Sign
- Battle sign, also known as mastoid ecchymosis, is a clinical sign indicative of a basal skull fracture 2
- It is characterized by bruising behind the ear, in the mastoid area, and is often accompanied by other signs such as raccoon eyes, otorrhea, and rhinorrhea 2
- The presence of Battle sign is correlated with head injury severity, as indicated by the Glasgow Coma Scale and Maximum Abbreviated Injury Scale-Head region 2
Management of Basal Skull Fracture
- The management of basal skull fracture, including those presenting with Battle sign, is often controversial, particularly with regards to the use of antibiotic prophylaxis 3, 4, 5
- Studies have shown that antibiotic prophylaxis does not appear to decrease the risk of meningitis in patients with basal skull fractures, regardless of the presence of cerebrospinal fluid leakage 3, 4, 5
- The current evidence does not support the use of prophylactic antibiotics in patients with basal skull fractures, although large, well-designed randomized controlled trials are needed to confirm these findings 4, 5
Clinical Value of Battle Sign
- The clinical signs of basal skull fracture, including Battle sign, have low accuracy, specificity, and positive predictive value for diagnosing this injury 2
- The presence of these signs is correlated with head injury severity, but their clinical value is limited, and they should not be used to make decisions about initial trauma care, such as the introduction of catheters and tubes via the nasal route 2