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injury to cranial nerves in relation to such fractures Fractures of the base are often dif cult to detect in plain skull lms, but their presence should always be suspected if any one of a number of characteristic clinical signs is in evidence Fracture of the petrous pyramid often deforms the external auditory canal or tears the tympanic membrane, with resultant leakage of CSF (otorrhea); or, blood may collect behind an intact tympanic membrane and discolor it If the fracture extends more posteriorly, damaging the sigmoid sinus, the tissue behind the ear and over the mastoid process becomes boggy and discolored (Battle sign) A Basal fracture of the anterior skull may also cause blood to leak into the periorbital tissues, imparting a B characteristic raccoon or panda bear appearance The presence of any of these signs calls for CT scanning of the skull base using bone window settings to detect a fracture The existence of a basal fracture is commonly indicated by signs of cranial nerve damage The olE factory, facial, and auditory nerves are the ones most liable to injury, but any one, including the twelfth, may be damaged Anosmia and an apparent loss of taste (actually a loss of perception of aromatic avors, since the elementary modalities of taste are unimpaired) are frequent sequelae of head injury, especially with falls on the back of the head In the majority of cases the anosmia is permanent If unilateral, it will C D not be noticed by the patient The mechanism of these disturbances is thought to be a displacement of the Figure 35-1 Mechanisms of craniocerebral injury A Cranium distorted by forceps (birth brain and tearing of the olfactory nerve laments in injury) B Gunshot wound of the brain C Falls (also traf c accidents) D Blows on the chin ( punch-drunk ) E Injury to skull and brain by falling objects [Reproduced by per- or near the cribriform plate, through which they mission from Courville (a study based on a survey of lesions found in a series of 15,000 course A fracture in or near the sella may tear the stalk autopsies)] of the pituitary gland, with resulting diabetes insipidus Rarely such a fracture may cause bleeding from a pre-existing pituitary adenoma and produce the syndrome of pirebral injury Even in fatal head injuries, autopsy reveals an intact tuitary apoplexy (page 577) A fracture of the sphenoid bone may skull in some 20 to 30 percent of cases (see also page 754) Conlacerate the optic nerve, with blindness from the beginning The trariwise, many patients suffer skull fractures without serious or pupil is unreactive to a direct light stimulus but still reacts to a prolonged disorder of cerebral function, largely because the energy light stimulus to the opposite eye (consensual re ex) The optic of a blow is dissipated in the fracture disc becomes pale, ie, atrophic, after an interval of several weeks The modern trend is to be concerned primarily with the presPartial injuries of the optic nerve result in scotomas and a troubleence or absence of brain injury rather than with the fracture of the some blurring of vision skull itself Nevertheless, fractures cannot be dismissed without Complete oculomotor nerve injury is characterized by ptosis, further comment for several reasons The presence of a fracture a divergence of the globes with the affected eye resting in an abalways warns of the possibility of underlying cerebral injury Overducted and slightly depressed position, loss of medial and most of all, brain injury is estimated to be 5 to 10 times more frequent with the vertical movements of the eye with diplopia, and a xed, dilated skull fractures than without them and perhaps 20 times more frepupil, as described in Chap 13 Diplopia that is worse on looking quent with severe and multiple fractures Moreover, fractures asdown, and compensatory tilting of the head suggest trochlear nerve sume importance by indicating the site and possible severity of injury In a series of 60 patients with head injury, Lepore found brain damage, in providing an explanation for certain cranial nerve that fourth nerve palsy was the commonest cause of diplopia, ocpalsies, and in creating potential pathways for the ingress of baccurring unilaterally twice as often as bilaterally, followed in freteria and air or the egress of cerebrospinal uid (CSF) In all these quency by damage to one or both third nerves, then, least often, a respects, fractures through the base of the skull are of special sigunilateral or bilateral sixth nerve palsy Five of his patients had ni cance, more so than those of the cranial vault, and are considpalsies that re ected damage to more than one nerve, and seven ered below had supranuclear disorders of convergence The long subarachnoid course of the fourth nerve is usually given as the explanation for Basal Skull Fractures and Cranial its frequent injury, but this mechanism has never been validated Nerve Injuries These optic and ocular motor nerve disorders must be distinguished from those due to displacement of the globe as a result of direct Some of the major sites and directions of basilar skull fractures are injury to the orbit and the oculomotor muscles indicated in Fig 35-2 One can readily perceive the possibilities of
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