2.  33 YOF brought in by
EMS after attending a
high school baseball
game, and being struck
behind the right ear by a
flying baseball bat while
sitting in the stands. She
c/o pain behind R ear,
tinnitus, dizziness, and
slurred speech. Denies
LOC, N/V.
 AFVSS
 Gen: WDWN, A&Ox4
 HEENT: NC/AT, PERRL,
EOMi, nml bilat visual
acuity, bilat TMs intact,
right hemotympanum,
right facial motor
weakness, TTP right
mastoid w/o
retroauricular ecchymosis
 Neuro: GCS-14 (Eyes 3),
nml sensation x 4, 5/5
motor strength x 4

4. 1. Air in Internal Auditory
Canal (thin arrow).
2. Transverse temporal bone
fracture (thick arrow).
3. Normal suture line
between temporal and
occipital bones.

5.  Non contrast CT head:
 necessary for suspected basilar skull fx.
 r/o TBI, intracranial bleeds
 +/- Prophylactic antibiotics for CSF rhinorrhea/otorrhea:
 should be done in consultation with Neurosurgery/ENT as
most CSF leaks will resolve spontaneously in one week w/o
complications
 if patient presents 1 wk s/p CSF leak with fever, Abx are
warranted, along with meningitis work-up (LP included)
 Broad coverage Abx w good penetration into meninges, eg.
Ceftriaxone, Vancomycin IV
 Tetanus prophylaxis
 Neurosurgery/Otolaryngology consultation

6.  Signs/symptoms of Basilar Skull Fracture:
Blood in ear canal
Hemotympanum
Rhinorrhea/Otorrhea
Battle's sign (retroauricular hematoma)
Raccoon sign (periorbital ecchymosis)
 Cranial nerve deficits
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Facial paralysis
Decreased auditory acuity
Dizziness/Vertigo
Tinnitus
Nystagmus

7.  Most basilar skull fractures (BSF) involve petrous portion
of temporal bone, external auditory canal and TM, but may
occur anywhere from cribriform plate to occipital condyle.
 Torn dura leads to otorrhea/rhinorrhea
 May be only sign of basilar skull fracture
 Perform and document thorough HEENT exam
 BSF may be subtle on CT scan
 Look for air/fluid levels in sinuses; pneumocephalus suggests
open fx
 Periorbital and mastoid ecchymoses develop slowly (up to
12-24 hours s/p injury), and often absent in ED.

8. Battle’s Sign
(retroauricular
ecchymosis)
Raccoon’s Sign
(periorbital ecchymoses)
Hemotympanum

9.  http://www.Cybermedicine2000.com
 Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of

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
Emergency Medicine, 3rd ed: http://www.accessmedicine.com
Marx: Rosen’s Emergency Medicine, 7th ed. Ch 38: Head Injury
Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for
preventing meningitis in patients with basilar skull fractures.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004884
Schwartz DT: Emergency Radiology: Case Studies:
http://www.accessemergencymedicine.com
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
7th ed. Chapter 254: Head Trauma in Adults and Children