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Case 1
Published in Edward Schwarz, Tomos Richards, Cases of a Hollywood Doctor, 2019
Edward Schwarz, Tomos Richards
Base of skull fractures are uncommon; however, they are a favourite question to ask in exams due to their classical clinical signs: Battle’s sign – bruising behind the ear, over the mastoid process of the temporal bone.Rhinorrhea or otorrhoea (due to CSF leakage).‘Racoon’ eyes – bruising around the eyes.
Head injury
Published in Ian Greaves, Keith Porter, Chris Wright, Trauma Care Pre-Hospital Manual, 2018
Ian Greaves, Keith Porter, Chris Wright
There may be evidence of airway obstruction with blood, vomit, foreign bodies or soft tissue swelling. Associated facial or cranial trauma must be identified. Signs include bruising, lacerations, fractures, boggy swellings, CSF leak from the ears or nose, and Battle’s sign suggestive of a base of skull fracture. Airway management needs to be prompt, as patients with a depressed level of consciousness are less capable of protecting their own airway. The airway should be cleared and initially maintained with simple airway manoeuvres or airway adjuncts as required. Simple measures include jaw thrust and chin lift (to allow for cervical spine control); head tilt should be a last resort. Adjuncts, including supraglottic airway devices and suction, should be used where necessary, although all can raise ICP. There is a theoretical risk that nasopharyngeal airway devices may enter the cranium via a basal skull fracture. However, if the airway is in jeopardy and no other airway devices are appropriate, their use should still be considered. In practice, penetration of the cranium is unlikely with careful insertion and would require a very large basal skull defect indeed. If the skill set is available, intubation is the definitive airway procedure, allowing the airway to be secured and optimal ventilation and oxygenation to be achieved. Mobile medical teams with the appropriate skill set can provide drug-assisted intubation (see later). However, there is always a need to balance the delay on scene resulting from achieving a secure airway with rapid transfer to the receiving hospital following simple manoeuvres.
Ear trauma
Published in S. Musheer Hussain, Paul White, Kim W Ah-See, Patrick Spielmann, Mary-Louise Montague, ENT Head & Neck Emergencies, 2018
Falls, assaults and road traffic accidents may cause a temporal bone fracture. Fractures are classified as longitudinal or transverse, but most tend to be mixed. Longitudinal fractures comprise 80% of all temporal bone fractures and are frequently caused by a blow to the temporo-parietal region; the fracture line is parallel to the long axis of the petrous temporal bone. Transverse fractures comprise 20% of all temporal bone fractures. They are usually secondary to a blow to the frontal or occipital region; the fracture line runs at a right angle to the long axis of the petrous pyramid and may also run through the otic capsule. A temporal bone fracture should be suspected in the presence of Battle’s sign (Figure 16.2a), peri-orbital ecchymosis (racoon sign), blood in the EAC, haemotympanum (Figure 16.2b), TM perforation, CSF otorrhoea and a lower motor neurone facial nerve palsy.
Spontaneous periocular ecchymosis: a major review
Published in Orbit, 2023
Matthew J. Hartley, Pav Gounder, Huw Oliphant
Periocular ecchymosis, or periocular bruising, is a common clinical finding where patients present with a variable degree of discoloration to the eyelids and periocular tissues, sometimes bilaterally. The skin of the eyelids is unique and among the thinnest in the human body.1 This, combined with an extensive vascular network with numerous anastomoses, means the periocular region is prone to bruising.2 The most common etiology is trauma including soft tissue injury, facial fractures, and skull base fractures, where mastoid ecchymosis – known as Battle’s sign – can also be observed. Various surgical and laser procedures including those performed by otolaryngologists, maxillofacial, ophthalmic, and plastic surgeons can also lead to periocular ecchymosis. The pathophysiology of bruising in these traumatic settings is crush damage and/or shearing forces to vascular beds that leads to extravasation of blood into soft periocular tissue planes.
Pediatric minor head trauma in Brazil and external validation of PECARN rules with a cost-effectiveness analysis
Published in Brain Injury, 2020
Leopoldo Mandic Ferreira Furtado, José Aloysio da Costa Val Filho, André Ribeiro dos Santos, Raísa Furfuro e Sá, Bruno Lacerda Sandes, Yangpol Hon, Eustáquio Claret dos Santos Júnior, Rodrigo Moreira Faleiro
In this referral center, minor head trauma is usually assessed following the protocol suggested by the Brazilian Society of Neurosurgery, in which minor head trauma is classified as high, middle, or low risk based on the risk features presented by the patient. High risk was defined as a patient presenting with non-accidental trauma and signs of skull base fracture, such as raccoon eyes and Battle’s sign. Middle risk was defined as children who suffered a high-intensity trauma mechanism, and low risk was defined as asymptomatic children who experienced a low-intensity trauma mechanism. This protocol gives the choice of performing a skull X-ray for low-risk minor head trauma and recommends CT for middle- and high-risk patients (18) (Figure 1).