A basal skull fracture or skull base fracture is a life-threatening injury to the head. It occurs as a result of force and can result in brain damage. A skull base fracture should not be confused with a concussion.
What is a basilar skull fracture?
First aid for traumatic brain injury and the typical symptoms. Click image to enlarge. The base of the skull forms what is known as the cerebral skull. Therefore, if the base of the skull is fractured, the brain may also be injured or cerebrospinal fluid may leak: Neurological disorders are a possible consequence. The edge of the fracture runs along the bone sutures; these are the points where the individual skull plates initially grow together by means of connective tissue in infancy. The tissue ossifies progressively as the child ages. However, the cranial sutures remain thinner than the solid cranial plates and are therefore more prone to fracture. Most commonly, a skull base fracture results from a break between the ear and the base of the skull or between the nose and the base of the skull.
Causes
A skull base fracture is the result of physical force and can occur, for example, in traffic accidents. Car accidents in which one of the persons involved hits the steering wheel or dashboard head-on are virtually predestined for this type of injury. This happens especially when the person is not wearing a seat belt. Another cause of a skull base fracture can be falls from a greater height that result in an impact to the head. Less commonly, a skull base fracture occurs as a result of direct personal force, i.e., a forceful blow to the face. In all of these variants, there may be a lesion of the orbits, ethmoid bone, frontal sinuses, and sphenoid sinus.
Symptoms, complaints, and signs
In a basilar skull fracture, symptoms differ depending on whether the petrous bone is fractured longitudinally or transversely. In a longitudinal fracture, different nerves and vessels are damaged than in a transverse fracture. If the bone is fractured longitudinally, a hematoma results from bleeding around the eyes. It can occur on one side (monocular hematoma) or on both sides (spectacle hematoma). In addition, the eyelids swell. If the orbital floor is also fractured, the eyes may sink deeper into the skull. In most cases, the paranasal sinuses are also injured in the longitudinal fracture. This causes a bony step to form at the external auditory canal. In addition, the eardrum may rupture and the ossicular chain may be disrupted, resulting in impaired hearing function. Olfactory nerves may also be injured. Paralysis of the facial nerve is rare in longitudinal fracture, but more common in transverse fracture. In the case of transverse fracture, it is mainly the ear that is damaged. Affected persons can no longer hear anything and their sense of balance is impaired. A hematoma forms behind the ear. In exceptional cases, an infection may develop that rises through the ear canal. In both types of skull base fracture, cerebrospinal fluid may flow as clear fluid from the nose, ear, or mouth. Trickles of blood may also escape. In addition to these symptoms, patients suffer from severe headaches and impaired consciousness, which can lead to unconsciousness.
Diagnosis and course
A skull base fracture can cause cerebrospinal fluid and blood to leak. However, because the skin usually remains intact despite the injury, the fluids do not seep directly from a wound: they make their way through the nose, mouth, or ears. Depending on exactly where the base of the skull breaks, the eyeball may be pushed forward or pulsate. The latter occurs due to blood entering from the internal carotid artery if it is damaged. In addition, hematomas (“bruises”) may appear in the eye sockets, taking the form of glasses. This phenomenon can also occur with other fractures in the head area. The fracture itself can be easily detected with the help of imaging techniques. In addition to these visible changes, neurological disorders can result from a skull base fracture – temporary or permanent. Disorders of consciousness such as unconsciousness or clouding of consciousness can be immediate consequences. Secondary damage from a skull base fracture is also possible: if blood from an injured vein enters the brain, further complications arise; up to and including failures of brain areas and the death of nerve cells.
Complications
In most cases, a skull base fracture is not associated with complications. This is especially true if there is no leakage of cerebrospinal fluid (CSF) and the meninges have not been affected. However, some patients experience severe effects of the injury, which in turn can have serious consequences and worsen the prognosis. One of the feared consequences of a skull base fracture is the leakage of cerebrospinal fluid. This involves liquid secretion flowing from the nose. If this occurs, the patient must be given antibiotics because otherwise there is a risk of ascending meningitis. Furthermore, there is a risk of the formation of a brain abscess, which is also the consequence of cerebrospinal fluid. Also among the conceivable complications is osteomyelitis, in which inflammation of the skull bones occurs. Another effect can be the development of a cerebrospinal fluid fistula. In this case, a duct forms between the meninges as well as adjacent body structures in the external direction. In turn, pathogens such as bacteria can enter through this inlet via the nose or ear. A feared complication of the skull base fracture is the increase in intracranial pressure. The human brain is extremely sensitive to pressure. As a result, there is a risk of convulsions, loss of consciousness or a life-threatening respiratory arrest. Because of this, there is a risk that the affected person will suffocate, artificial respiration is necessary. The acute risk of suffocation basically prevails in the case of a skull base fracture, if the patient becomes unconscious in the process.
When should you go to the doctor?
In the case of a skull base fracture, a doctor must be consulted immediately. There can be no self-healing in this condition, and without treatment, the bones can fuse together incorrectly. Therefore, to avoid further complications and damage to the brain, a doctor should always be consulted for a skull base fracture. The doctor should be consulted if the affected person has a severe bruise on the head and suffers from a very severe headache. Furthermore, swollen eyelids also indicate the skull base fracture. Especially after a fall or after another severe injury, these complaints can indicate the skull base fracture. In some cases, hearing difficulties or paralysis in the face may also indicate this fracture and should be examined by a doctor. It is also not uncommon for those affected to experience loss of consciousness or suffer from an impaired sense of balance. In the case of a skull base fracture, a general practitioner can be consulted in the first instance. However, in the case of very serious complaints or after an accident, an emergency doctor can also be called or the hospital visited.
Treatment and therapy
Bleeding due to a skull base fracture can be prevented or stopped by immediate surgical intervention. Similarly, cerebrospinal fluid may be released. In this case, vessels may also need to be sutured, for example, the internal carotid artery. Since the outer meninges are often torn in a basilar skull fracture, these must also be subsequently sutured. The actual fracture is carefully straightened and the fracture sites are fixed with the help of various materials so that the skull can grow back together and the bones do not fuse or grow together crookedly. The material used for this purpose is preferably the body’s own (connective) tissue, as there is no risk of a repulsive reaction from the organism. In addition, the biological fibrin glue can provide valuable services: it acts as a two-component adhesive. In rarer cases, metal plates must be inserted into the skull. If the eyes and/or ears have been affected by the skull base fracture, surgery is performed here as well. This is particularly important in order to counteract the expected impairments of the sense of sight or hearing at an early stage. If the skull base fracture does not lead to leakage of cerebrospinal fluid or blood and there is no other damage, surgery is not necessary. In particular, fractures between the nose and the base of the skull tend to be mild.
Prevention
Because a skull base fracture is caused by violent forces, there is no direct way to prevent it. However, general safety measures such as wearing a seat belt while driving can prevent physical force from occurring in the first place.
Aftercare
In most cases, a basilar skull fracture is associated with concussion. Therefore, affected individuals are advised to take excessive rest during the acute period. This includes refraining from unnecessary stress and avoiding sports activities so that blood pressure is not increased. Likewise, bending the head and long, hot bathing should be avoided. Stays in the sun should also be refrained from. Affected individuals should urgently avoid situations that can agitate them. A balanced sleep rhythm is very important. Affected persons must get enough sleep after the operation in order to recover as quickly as possible. If these points of aftercare are observed, not only healing can be accelerated, but also complications. Mechanical stress to the body should be refrained from by affected individuals until full recovery. Any sports that involve contact with the head should not be practiced. These include, for example, martial arts, yoga and soccer. These sports carry too high a risk of further head injuries. If affected persons ride a bicycle, wearing a helmet is mandatory. If visual disturbances or headaches occur, affected persons should in any case consult a doctor in order to be able to rule out complications of the operation.
What you can do yourself
The base of the skull fracture is a trauma that first of all absolutely belongs to medical treatment. However, self-help of the patient is also very important in order not to endanger the recovery and to make it optimal. Since the base of the skull fracture is often associated with a concussion, sparing is essential in the acute phase. This includes not only physical rest and refraining from any sporting activity. It also involves avoiding activities that raise blood pressure. This includes bending the head forward as well as hot baths or spending time in the sun. Excitement should also be avoided at all costs during the acute phase. Sufficient sleep is important. Even after the acute phase, self-help can not only accelerate regeneration but also prevent complications. The skull base fracture often heals without problems, but mechanical stress on the skull must be avoided during this time. This includes, for example, avoiding appropriate sports that could put stress on the head. These include martial arts with full contact as well as the headstand in yoga or ball sports, which can put stress on the skull again with the header in soccer or the possibility of a head kick by the ball in handball. When cycling or similar activities, the helmet is mandatory for the phase after the fracture. Headaches or visual disturbances are reason to see a doctor.
