What are the signs and symptoms of a basal skull fracture in a young adult patient?

Signs and Symptoms of Basal Skull Fracture

Basal skull fractures present with specific physical examination findings that include periorbital ecchymosis (raccoon eyes), retroauricular ecchymosis (Battle's sign), hemotympanum, CSF rhinorrhea or otorrhea, and cranial nerve deficits—these signs are critical high-risk features that mandate immediate CT imaging and neurosurgical consultation regardless of Glasgow Coma Scale score. 1, 2

Classic Physical Examination Signs

Periorbital and Auricular Findings

• Raccoon eyes (periorbital ecchymosis) is the most common clinical sign, present in approximately 64% of patients with basal skull fracture 3, 4
• Battle's sign (retroauricular ecchymosis) appears as bruising behind the ear over the mastoid process, though it characteristically takes several hours to develop after injury 1, 4
• Both signs indicate anterior or middle cranial fossa fractures and place patients in the high-risk category even with normal consciousness 1, 2

Otologic Signs

• Hemotympanum (blood behind the tympanic membrane or bloody fluid from the ear) is a direct sign of temporal bone involvement in the basilar skull fracture 1, 4
• CSF otorrhea indicates a dural tear with communication between the subarachnoid space and middle ear 3, 5
• Hearing loss may occur—either conductive (from middle ear involvement) or sensorineural (from inner ear/cranial nerve VIII injury) 4

Nasal and Facial Signs

• CSF rhinorrhea presents as clear fluid draining from the nose, indicating anterior cranial fossa fracture with dural tear 3, 5
• Physical evidence of trauma above the clavicle should raise suspicion for basilar skull fracture 6

Neurologic Deficits

• Cranial nerve injuries are common complications, particularly involving cranial nerves I, II, VII, and VIII depending on fracture location 5, 4
• Vestibular symptoms including dizziness and nausea may occur with petrous bone fractures affecting the labyrinth 4

Critical Clinical Context

Risk Stratification

• Signs of basilar skull fracture automatically classify patients as high-risk for severe intracranial injury regardless of GCS score 1, 2
• The Canadian CT Head Rule identifies "sign of basal skull fracture" as one of five high-risk factors mandating immediate CT imaging 6
• Even patients with GCS 15 require CT imaging and admission when basilar skull fracture signs are present 2

Associated Injuries

• Basilar skull fractures occur in approximately 3.85% of all head injury patients but are associated with moderate-to-severe traumatic brain injury in 73% of cases 3
• These fractures carry high risk for associated intracranial hemorrhage, contusions, and vascular injuries including arterial dissection 1, 2
• CSF leak occurs in approximately 22% of basilar skull fracture cases (43 of 194 patients in one series) 3

Common Pitfalls to Avoid

• Do not assume GCS 14-15 represents "mild" injury when basilar skull fracture signs are present—these patients require aggressive management with immediate CT imaging 1, 2
• Do not delay CT imaging to observe the patient first, as imaging must be performed systematically and without delay 1, 2
• Do not discharge based on "normal vital signs" alone, as vital signs do not predict intracranial injury severity in head trauma 1
• Do not miss Battle's sign by examining too early—this sign may take hours to develop, so re-examination is essential 1
• Clinical signs are supportive but not definitive—high-resolution CT with bone windows is the gold standard for detecting basilar skull fractures, as these fractures can be subtle or missed on clinical examination alone 3, 5

Immediate Management Implications

When any sign of basilar skull fracture is identified:

• Obtain immediate non-contrast head CT with bone windows to characterize the fracture pattern and identify associated intracranial injuries 1, 2
• Perform CT angiography of supra-aortic and intracranial vessels, as basilar skull fractures are a specific risk factor for traumatic arterial dissection 2
• Arrange immediate neurosurgical consultation, particularly if GCS is compromised or if associated intracranial hemorrhage is present 1, 2
• Admit for close neurological observation with serial examinations, even if initial GCS is 15 2