Question 2

With reference to base of skull fractures following trauma:

a) List 5 clinical signs commonly associated  with base of skull fractures.

b) List 3 life threatening complications specifically associated  with base of skull fractures

c) Briefly outline the role of prophylactic antibiotics in the management of base of skull fractures

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College Answer

a) List 5 clinical signs commonly associated  with base of skull fractures.

1)  CSF rhinorrhoea
2)  CSF otorrhoea
3)  Battle’s sign
4)  Raccoon eyes
5)  Haemotympanum
6)  Cranial nerve palsies.

b) List 3 life threatening complications of base of skull fractures

Basal meningitis
Carotid artery trauma or pseudoaneurysms
Cavernous sinus thrombosis

c) Briefly outline the role of prophylactic antibiotics in the management of base of skull fractures.

BOS # predispose patients to meningitis because of possible direct contact of bacteria in paranasal sinuses, nasopharynx or middle ear with CNS. Also CSF leak is associated with a greater risk of contacting meningitis. Few RCTs exist and the primary end point was a reduction in meningitis.

1) No role for prophylactic antibiotic therapy whether there is CSF leak or not.
2) Do not reduce the risk of meningitis.


Features of base of skull fracture are better covered in Question 14.3 from the second paper of 2010.

Base of skull fracture is also asked about in Question 30.1 from the second paper of 2011.

In brief, the features are:

  • CSF otorrhoea
  • Haemotympanum
  • Racoon eyes (adults call it "bilateral periorbital haematoma")
  • CSF rhinorrhoea
  • Cranial nerve abnormalities:
    • CNI damage (loss of olfaction)
    • CN II entrapment (visual field defects or blindness)
    • CN VII palsy (facial paralysis)
    • CN VIII palsy (deafness)
  • Blephaerohaematoma (i.e. of the eyelid)
  • Pneumoencephalus (more of a radiological finding)
  • Bloody otorrhoea
  • CSF otorrhoea

Complications of a base of skull fracture include the following:

  • Meningitis/encephalitis
  • Carotid artery dissection
  • Cavernous sinus thrombosis
  • Pneumocephalus due to positive pressure ventilation
  • Accidental cannulation of the cranial cavity with the nasogastric tube
  • Carotido-cavernous fistula
  • CSF fistula

As for the antibiotics; a 1998 meta-analysis had concluded that "antibiotic prophylaxis after basilar skull fractures does not appear to decrease the risk of meningitis." This conclusion was supported bya 2011 Cochrane review.


Pretto, Flores L., C. S. De Almeida, and L. A. Casulari. "Positive predictive values of selected clinical signs associated with skull base fractures." Journal of neurosurgical sciences 44.2 (2000): 77-82.

Tubbs, R. Shane, et al. "William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture: Historical vignette." Journal of neurosurgery 112.1 (2010): 186-188.

Katzen, J. Timothy, et al. "Craniofacial and skull base trauma." Journal of Trauma and Acute Care Surgery 54.5 (2003): 1026-1034.

Samii, Madjid, and Marcos Tatagiba. "Skull base trauma: diagnosis and management." Neurological research 24.2 (2002): 147-156.

Villalobos, Tibisay, et al. "Antibiotic prophylaxis after basilar skull fractures: a meta-analysis." Clinical infectious diseases 27.2 (1998): 364-365.

Ratilal, Bernardo O., et al. "Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures." Cochrane Database Syst Rev 8 (2011).