What is the management approach for a patient with a basilar skull fracture, bloody fluid from the ear, and bilateral or unilateral peri-orbital ecchymosis?

Management of Basilar Skull Fracture with Periorbital Ecchymosis and Bloody Ear Drainage

Immediately obtain a non-contrast CT head with bone windows to confirm the basilar skull fracture, followed by CT angiography of the supra-aortic and intracranial vessels, as basilar skull fractures are a specific high-risk factor for traumatic arterial dissection that carries significant morbidity and mortality if missed. 1, 2

Immediate Imaging Protocol

• Perform CT head without delay using thin-section imaging with bone windows and double fenestration (central nervous system and bone windows) to fully characterize the fracture pattern and identify associated intracranial hemorrhage 1, 2

• Add CT angiography of supra-aortic and intracranial vessels because basilar skull fractures are an established risk factor for traumatic arterial dissection, which occurs in a significant proportion of these patients and requires early identification to prevent stroke 1, 2

• The presence of periorbital ecchymosis (raccoon eyes) and bloody ear drainage are classic signs of basilar skull fracture, though these signs are present in only a minority of cases—hemotympanum occurs in 58% and ear canal bleeding in 47% of pediatric basilar skull fractures 3, 4

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg at all times using immediate vasopressor support (phenylephrine or norepinephrine) if hypotension develops, rather than waiting for delayed effects of fluid resuscitation 1, 2

• Avoid hypotensive sedative agents during initial management, as even a single episode of systolic blood pressure <90 mmHg significantly worsens neurological outcomes 2

• Monitor tissue perfusion continuously through base excess, arterial lactate, and urine output 5

Airway and Ventilation

• Secure the airway early with endotracheal intubation if Glasgow Coma Scale is compromised or if there is risk of deterioration, as airway control is a priority that decreases mortality in trauma patients 1, 2

• Maintain end-tidal CO2 monitoring to prevent both hypercapnia and hypocapnia, as hypocapnia induces cerebral vasoconstriction and increases risk of brain ischemia 1, 2

Neurosurgical Consultation

• Obtain immediate neurosurgical evaluation for any patient with basilar skull fracture who has acute subdural or epidural hematoma, multiple hemorrhagic contusions, significant mass effect or midline shift, or deteriorating neurological examination 1

• Even patients who do not require neurosurgical procedures benefit from management in neurosurgical centers due to accumulated expertise and lower mortality rates 2

Admission and Monitoring

• Admit all patients with basilar skull fractures for close neurological observation with serial neurological examinations, as signs of basilar skull fracture place patients in the "high risk" category even with Glasgow Coma Scale of 15 1, 6

• Repeat CT imaging at 6-12 hours if initial examination shows associated intracranial injury 1

• Monitor for delayed complications including vascular injury/dissection, cerebrospinal fluid leak (otorrhea in 26% of pediatric cases, rhinorrhea in only 1.6%), and cranial nerve injury (facial nerve paralysis in 13% of pediatric cases) 1, 3, 4

Assessment for Associated Injuries

• Evaluate for cranial nerve injury, which is the most common clinical feature associated with periorbital ecchymosis in trauma patients (observed in 28% of cases with periorbital ecchymosis) 4

• Check for other classic signs of basilar skull fracture including Battle's sign (post-mastoid ecchymosis), hemotympanum, and cerebrospinal fluid leaks, though these are rarely present together—only 3 of 36 patients with periorbital ecchymosis had Battle's sign in one series 4, 7

• Assess hearing, as 34% of pediatric patients with basilar skull fractures complain of hearing loss 3

Critical Pitfalls to Avoid

• Do not discharge patients with basilar skull fractures without adequate observation, even if initial Glasgow Coma Scale is 15, as the presence of basilar skull fracture signs automatically places them in high-risk category 1, 6

• Do not miss associated vascular injuries—always obtain CT angiography given the high-risk nature of basilar skull fractures for arterial dissection, as blunt cerebrovascular injury carries significant morbidity and mortality if not identified and treated early 1, 2

• Do not assume periorbital ecchymosis always indicates basilar skull fracture—in one series, only 42% of patients with periorbital ecchymosis had basilar skull fractures, while 25% had only soft tissue injuries and 22% had convexity fractures 4