Skull fractures may present with localized swelling and pain; subcutaneous bleeding over the mastoid process (Battle sign) or around the orbit (raccoon eyes); blood behind the tympanic membrane (hemotympanum); or CSF leak from the nose (rhinorrhea) or ear (otorrhea). Rarely, a few weeks to months after linear skull fractures, a soft, pulsatile scalp mass is palpable; radiographically, the fracture edges are separated by a soft tissue mass that consists of fibrotic tissue and accumulated brain and meningeal tissue and, possibly a leptomeningeal cyst. The recommended treatment of leptomeningeal cysts involves surgical excision of abnormal tissue and dural repair.
CSF leak occurs when a skull fracture tears adjacent dura, creating communications between the subarachnoid space and the nose, paranasal sinuses, mastoid air cells, or ear. Clear fluid that leaks from the nose or ear after head trauma is presumed to be CSF until proved otherwise. The presence of air within the subdural, subarachnoid, or ventricular space also indicates a dural tear and open communication between the nose or paranasal sinuses and brain. In most cases, the dura heals spontaneously when the patient’s head is kept elevated. Patients with CSF leaks are at risk for the development of meningitis or extradural abscesses. If the leak persists or recurs or if meningitis develops, the dura is surgically repaired. Cranial nerve palsies, secondary to a laceration or contusion of the cranial nerves, may result from a skull fracture and may be transitory or permanent. Longitudinal fracture of the petrous bone produces a conductive hearing loss and facial palsy, which begin hours after the injury and usually resolve spontaneously. Transverse petrous fractures produce sensorineural hearing loss and immediate facial palsy with a poor prognosis for spontaneous recovery. Disruption of the ossicular chain can cause hearing loss and may necessitate surgery. Vestibular disturbances, producing prolonged posttraumatic vertigo, are extremely common. Permanent loss of olfaction after a head injury is the result of a rupture of the thin olfactory nerves within the cribriform plate. Disruption of cranial nerves III, IV, and VI produces ophthalmoplegia, diplopia, and head tilt. Even seemingly minor head injuries can produce sixth nerve palsy with medial deviation (or incomplete abduction) of one or both eye(s).
Other Complications of Head Trauma
Cervical spine injuries must be suspected in any unconscious child, especially if bruises are present on the head, neck, or back. In conscious children, findings of neck or back pain, burning or stabbing pains radiating to the arms, paraplegia, quadriplegia, or asymmetrical motor or sensory responses of arms or legs suggest spinal cord injury. Cervical spine injury (displaced or fractured vertebra) may result in complete transection of the cord with spinal shock, loss of sensation, and flaccid paralysis. A contused cord (without vertebral abnormality) may present in a similar manner. Any patient with a clinical or radiologic abnormality of the spine requires immediate spine and cardiopulmonary stabilization and neurosurgical consultation.