Skull base fracture
Base of skull fracture
English: basal skull fracture
Skull base fracture describes the injury to the bones of the base of the skull, the lower part of the human Brain skull.
The skull base fracture is one of the skull fractures, which are divided as follows:
- Skull fractures (Skull fracture)
- Skull base fractures (Base of skull fracture)
- Facial skull fractures
The base of the skull is made up of parts of the Frontal bone (Frontal bone), Sphenoid bone (Sphenoid bone), Ethmoid (Ethmoid bone), Occiput (Occipital bone) and Temporal bone (Temporal bone) educated. The inner skull base is divided into three pits: front (Anterior cranial fossa), middle (Fossa cranii media) and rear (Posterior cranial fossa) Cranial fossa. It forms the floor of a cave in which the brain is located.
Symptoms of a skull base fracture
The possible externally visible symptoms of a skull fracture include classic bruises, such as a hematoma of glasses (Bleeding into the skin around the eyes / eye sockets when wearing glasses) or visible bleeding into the eye socket (Monocular hematoma).
Bleeding into the space behind the eye can lead to a spatial displacement of the eye forwards so that it emerges. (s. also Pain behind the eye)
If the eye also pulsates, this can even be an indication of bleeding from the torn or completely torn inner carotid artery.
In addition, if there is an open connection between the CSF space (Space between the brain and meninges) and the nasal cavity or the external auditory canal lead to a visible leakage of clear cerebral fluid from the mouth, nose or ears. If smaller or larger vessels are injured by the trauma at the same time, the clear liquor fluid can also be bloody.
The invisible, neurological symptoms include disorders of consciousness such as clouding of consciousness or even complete loss of consciousness.
The blood vessels in the brain, which may have been ruptured as part of the skull base fracture, can also cause symptoms of a stroke through bleeding into the brain tissue. These include paralysis, numbness, visual disturbances, speech disorders and severe headaches.
In the same way, individual cranial nerves that originate in the brain and leave the cranial cavity through various openings in the base of the skull can be pinched by the break and cause symptoms such as dizziness, blindness, paralysis in the facial muscles, hearing and smell loss.
Read more on the topic: Symptoms of a skull base fracture
In order to make a diagnosis, it is important to first ask about the patient's medical history and the possible cause of the accident, as well as the physical examination, paying particular attention to external injuries, consciousness, pupillary reactions and the function of the cranial nerves.
Then a cranial one is made Computed tomogram (cCT) (CT of the head), which also allows assessment of the brain and possible bleeding.
In addition, a X-ray of the skull and the Cervical spine can be done, which is usually not necessary if the cCT is present. If in addition to the Skull base fracture the brain, cranial nerves or the eye socket are injured, can be an alternative to a computed tomogram MRI of the head be made.
If liquid leaks from the nose or ear, its origin is determined using a special substance. The crucial question, namely whether the liquid is CSF, is tested by determining the content of? 2-transferrin (iron transport protein). If the result is positive, the liquid is cerebrospinal fluid (cerebral fluid) and comes out of the head, as only this substance is contained in it.
Of the Skull base fracture is divided into two groups depending on its location:
- frontobasal fracture
- laterobasal fracture
The frontobasal Skull base fracture Affects the nose and sinuses and is located in the front of the skull. The laterobasal skull base fracture includes the ear and temporal bone and lies on the side of the skull. They can be further subdivided into a longitudinal fracture of the temporal bone (fracture line in the longitudinal direction) and a transverse temporal bone fracture (fracture line in the transverse direction).
Another classification takes into account the type of skull base fracture:
- Burst fracture = Caused by extensive violence from the side; the bone bursts, shifting the fragments outwards in a circle
- Impression fracture = Occurrence in the event of acute violence
The frontobasal skull base fracture is usually caused by accidents (work, traffic accidents) after the use of force on the forehead and nose area. The laterobasal skull base fracture, on the other hand, occurs after lateral force (Longitudinal temporal bone fracture) or after applying force to the forehead or the occiput (Temporal bone fracture).
The Therapy one Skull base fracture depends on the extent of the injury. If there is no shift (Dislocation) of the individual fragments, no therapy is required other than initial monitoring for bleeding. A CSF leak from the ear (otogenic liquorrhea) in the case of a laterobasal fracture, use Administration of antibiotics treated.
The therapy looks different if in addition to the skull base fracture Cranial nerves Are injured or liquor is leaking from the nose (frontobasal fracture). In these cases surgical treatment is combined with Antibiotic treatment to strive for. During the operation, the bony structures are taken care of and the meninges surrounding the brain are sewn.
A Cranial bass fracture is by no means a life-threatening injury in all cases, so that emergency intervention or intensive therapy is not always necessary.
If, for example, there are only fine cracks in the base of the skull or if the individual, small fragments are not shifted against each other, the health of the person affected is usually restored within days to weeks.
Surgical therapy or intensive treatment is not necessary in these cases, but inpatient hospital monitoring is necessary in order to recognize and treat possible late symptoms or complications in good time.
In the case of accompanying injuries (vascular tears, nerve entrapment, eye injuries) or open skull base fractures, however, immediate surgical intervention is unavoidable and may save lives. How much time a full recovery takes in such cases depends entirely on the extent of the accompanying injuries and possible complications, although an average of weeks to months must be assumed.
The Duration until a skull base fracture has healed cannot be assessed across the board. At a simple fracture of the base of the skullwhere the fragments not shifted against each other and at that no accompanying injuries are present, those affected can usually already after a few days to a few weeks take part in life completely normally and without restrictions again. A surgery is usually in such cases unnecessary, a Hospitalization on the other hand, since serious problems may occur here Complications can be recognized and treated directly.
However, when surgery was necessary, there was Skull bones have shifted against each other or are split, so the patient must on the one hand long in hospital stay and on the other hand too protect at home for a long time, as operations on the skull are a serious procedure. In addition, if metal plates have been inserted beforehand to secure the skull, the Operations to remove these plates and screws on. If nerves were injured in the skull base fracture, it takes time several weeks to months before they have regenerated, as nerve tissue grows very slowly. In addition, there is usually a long-term physiotherapy necessary to regain the original function. Permanent damage is always possible here. Was that with the skull base fracture brain Affected, even motor, sensory or cognitive limitations arose, the healing process is possible in principle, but it is necessary usually a lot of time, up to years. In addition, consistent rehabilitation must take place here. However, when the brain is involved, consequential damage, the severity of which can vary widely, remains.
Consequences of a skull base fracture
The consequences of a skull base fracture largely depend on the possible accompanying injuries and (late) complications.
An uncomplicated fracture of the base of the skull without accompanying injuries orComplications and unshifted fragments usually heals without consequences after a few days to weeks.
The undesirable complications and consequences of a complicated skull base fracture include, for example Infection of the brain or the Meninges (Encephalitis/ meningitis), the Increase in intracranial pressure with the risk of unconsciousness or des Respiratory and / or circulatory arrest, the Blindness due to the optic nerve entrapment, Bleeding from larger vessels with subsequent Stroke symptoms, Disturbances in equilibrium- and Hearing ability, a permanent one Tinnitus or the complete loss of smell.
In addition, the risk increases over time epileptic seizure or a epilepsy to suffer, the more severe the trauma and the more complicated the fracture of the base of the skull is.
Normally, a fracture of the skull base heals without any consequences and does not require medical intervention. This prognosis is particularly true if no CSF escapes, i.e. the meninges are uninjured. However, complications can arise that make therapy essential for survival. These complications also determine whether and how severe permanent and reversible consequential damage occurs. Depending on the number and severity of complications that occur, the prognosis varies between very good and very bad.
If the meninges are damaged, liquor (cerebral fluid) usually escapes, which is usually noticeable in the fact that liquid secretion escapes from the nose (nasal liquorrhea). In this case, antibiotics should be used, as otherwise the risk of developing meningitis (meningitis) is increased.
In addition, a brain abscess can form as a result of an infection with liquorrhea. Inflammation of the skull bones (osteomyelitis) as a result of an infection is also possible. In addition, a liqour fistula, i.e. a passage between the meninges or other structures with a connection to the outside, can form, which then ultimately encourages the entry of bacteria and other pathogens through the ear or nose into the skull.
In addition to the consequences of a skull base fracture triggered by germs, intracranial pressure can also increase due to swelling or bleeding after a vessel has been injured. An increase in intracranial pressure poses a particular danger, as the brain is very sensitive to pressure. The consequences can be loss of consciousness, convulsions, or even respiratory failure. Then there is an acute risk of suffocation and the patient must be ventilated. In general, if one breaks the base of the skull, one can become unconscious, even then there is an acute risk of suffocation.
Further consequential damage can be the blindness of the patient, this danger threatens if the break line through the eye socket (Orbit) and entrapment of the eye nerves (optic nerve) occurs. Another consequential damage affecting nervous structures is facial paralysis (paralysis of the Facial nerve). If the facial nerve is paralyzed by being pinched by bony structures, this has far-reaching consequences. For example, the entire facial muscles are paralyzed. In addition to the nerves, blood vessels can also be damaged. In particular, the internal carotid artery should be mentioned here; if it tears, heavy bleeding can occur. Different structures are injured depending on the fault line. If this goes through the inner ear, hearing damage and balance disorders can occur. In addition, the development of tinnitus (persistent whistling sound) is favored.
If the risk is particularly great and depending on the severity of the skull base fracture, the treating doctors can decide to give the patient a treatment Put an artificial coma. The artificial coma is a long-term anesthetic that is monitored by intensive care medicine. It is used when the patient's life is threatened. The body often overreacts in the case of very serious illnesses, such as a severe infection after a skull base fracture. The body's own rescue systems are then completely overwhelmed by this enormous stress. The artificial coma protects the patient and calms the body. While all major body functions such as blood pressure and heart rate are monitored all the time, doctors can treat the patient more effectively.
Read more on the topic: Cerebral hemorrhage coma
Complicated skull base fracture
It looks different with one complicated break, so if the individual fragments against each other postponed are. Then one should surgery take place in order to bring the fragments back into their correct position and, if necessary, with them Plates, wires and / or screws to stabilize. After the surgical procedure, patients must for a few days to weeks stay in the hospital to be watched. It can then take longer at home for those affected to feel completely fit again, since an operation on the skull is always uncomfortable major intervention and the body needs some time to restore it. Therefore one should stay for a long time after such an operation do not burden.
If the nose is broken too, surgery is often performed. It should also be noted that before or after the operation, there may be a reduction or loss of the olfactory ability, which also affects the taste. Most of the time, these restrictions recover over time, and those affected should be patient. Occasionally, these impairments may not fully recover.
When nerve cords have been damaged by a fracture of the base of the skull, sensory disorders or paralysis can occur, depending on which nerve cord was injured. Since nerves grow back very slowly, it often takes several weeks before they can perform their original function again. This also often requires consistent physiotherapy or rehabilitation time.
If the ear canal is injured as part of a skull base fracture, hearing impairment can occur. Some of these require surgical treatment, which is followed by a longer rehabilitation process. In some cases, however, they also lead to permanent hearing loss or hearing loss.
An extremely serious variant of the skull base fracture is when the brain is also affected. If there is a major cerebral hemorrhage, an operation must be carried out quickly to relieve the high pressure caused by the blood. In such patients it can happen that permanent damage to the brain and thus paralysis, sensitivity disorders and / or cognitive impairments occur. The healing of these complications definitely requires a long-term rehabilitation process. For some, residual symptoms can last for a lifetime.
Fracture of the base of the skull in a child
A traumatic brain injury in children and young children - caused by e.g. B. Falling from changing tables, falling down stairs or climbing frames - is unproblematic in most cases.
In a few cases, however, serious injuries such as a skull base fracture can also occur in the little ones. Diagnosis is not always easy due to the lack of communication skills in small children and deviating symptoms, which is why close observation of the child after the trauma is essential. Changed drinking behavior, reduced chattering, excessive tiredness or slower reactions in small children can already be an indication of impaired consciousness.
In general, after a traumatic brain injury, parents should pay attention to whether the child reacts normally, opens their eyes, feels tingling in their legs or arms a headache or nausea complains or vomits, clear fluid or blood comes out of the mouth, nose or ears and the pupils of the eyes are the same size.
The for traumatic brain injury The fracture of the skull base refers to the damage to the bony structures of the skull base, which is formed by the forehead, wedge, temple, ethmoid and occiput. The classification is based either on the type of fracture (burst, impression fracture) or on the location, whereby frontobasal (front) and laterobasal (lateral) fractures are separated.
The clinical picture is characterized by various forms of bleeding, loss of CSF via the nose or ear (Liquorrhea), Formation of bruises (glasses, monocle hematoma) and cranial nerve failure.
The most important thing for diagnosis is the preparation of a cranial one Computed Tomography (CT of the head), alternatively also a Magnetic resonance imaging (MRI of the head) can be carried out.
A fracture of the skull base only requires treatment if the fragments are displaced (Dislocation), Liquor leakage or injury to the cranial nerves occurs. In these cases, the fracture is treated surgically.
The occurrence of complications with skull base fractures such as ascending infection with meningitis (meningitis) and abscess formation worsen the prognosis.