What is the appropriate history, examination, and workup for a suspected basilar skull fracture?

Basilar Skull Fracture: History, Examination, and Workup

Immediate CT imaging is strongly recommended for all patients with clinical signs of basilar skull fracture for definitive diagnosis and risk stratification. 1

Clinical History

• Mechanism of injury (high-velocity blunt trauma, falls from height)
• Loss of consciousness
• Headache severity and location
• Vomiting episodes (more than once increases risk)
• Hearing changes, dizziness, or tinnitus
• Visual disturbances
• Fluid leaking from nose or ears
• Sensory changes or weakness in face

Physical Examination

Key findings to evaluate:

• Signs of basilar skull fracture:
  • Periorbital ecchymosis ("raccoon eyes")
  • Retroauricular ecchymosis (Battle's sign)
  • CSF rhinorrhea (clear fluid from nose)
  • CSF otorrhea (clear fluid from ear)
  • Hemotympanum (blood behind tympanic membrane)
  • Bleeding from ear canals
  • Cranial nerve deficits 1, 2
• Glasgow Coma Scale (GCS) assessment
• Neurological examination including all cranial nerves
• Otoscopic examination to assess for hemotympanum
• Test for CSF in nasal or ear drainage (halo sign)

Diagnostic Workup

Imaging

• Non-contrast CT scan of the head is the primary diagnostic tool 1

  • Evaluate for fracture lines in:
    • Anterior cranial fossa (cribriform plate, orbital roof)
    • Middle cranial fossa (temporal bone, sphenoid)
    • Posterior cranial fossa (occipital bone) 1
  • Assess for associated intracranial injuries (critical for prognosis)

• CT angiography if vascular injury is suspected 2

Additional Considerations

• If CSF leak is suspected but not confirmed, test fluid for beta-2 transferrin
• Insert orogastric rather than nasogastric tube if basilar skull fracture is suspected 3
• Avoid nasal instrumentation to prevent intracranial penetration

Risk Stratification and Management

High-Risk Features Requiring CT Imaging

According to the American College of Emergency Physicians guidelines:

• Clinical signs of basilar skull fracture
• GCS ≤ 13
• Focal neurological deficit
• Age > 60 years
• Loss of consciousness
• Severe headache
• Vomiting 1

Management Based on CT Findings

1. Patients with intracranial pathology plus basilar skull fracture:

   • Higher morbidity (11%) and mortality (7%)
   • May require neurosurgical intervention
   • Intensive monitoring required 4

2. Patients with no intracranial pathology but GCS < 13:

   • Moderate risk (2% morbidity, 2% mortality)
   • Close monitoring recommended 4

3. Patients with no intracranial pathology and GCS ≥ 13:

   • Low risk (1% complication rate, no neurologically related mortality)
   • Can be managed without intensive care monitoring 4

Important Caveats

• Antibiotic prophylaxis is NOT recommended for basilar skull fractures, even with CSF leakage. Evidence does not support this practice, and it may lead to more resistant organisms 5, 6
• Instead, monitor closely for early signs of meningitis and treat with appropriate antibiotics if it develops 6
• If maxillofacial trauma or basilar skull fracture is suspected, insert an orogastric rather than nasogastric tube to prevent intracranial penetration 3
• The presence of other intracranial injuries significantly increases morbidity and mortality 4
• Treatment is usually interdisciplinary and depends mainly on accompanying injuries and complications 2

Basilar skull fractures account for approximately 20% of all skull fractures and require careful assessment and monitoring due to potential serious complications including CSF leakage, meningitis, vascular injuries, and cranial nerve injuries 1, 2.