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Raccoon eyes are bilateral periorbital ecchymoses that don’t result from facial soft-tissue trauma. Usually an indicator of basilar skull fracture, this sign develops when damage at the time of fracture tears the meninges and causes the venous sinuses to bleed into the arachnoid villi and the cranial sinuses. Raccoon eyes may be the only indicator of a basilar skull fracture, which isn’t always visible on skull X-rays. Their appearance signals the need for careful assessment to detect underlying trauma because a basilar skull fracture can injure cranial nerves, blood vessels, and the brain stem. Raccoon eyes can also occur after a craniotomy if the surgery causes a meningeal tear.
After raccoon eyes are detected, check the patient’s vital signs and try to find out when the head injury occurred and the nature of the head injury. (See Recognizing raccoon eyes.) Then evaluate the extent of underlying trauma.
Start by evaluating the patient’s level of consciousness (LOC) using the Glasgow Coma Scale. (See Glasgow Coma Scale, page 374.) Next, evaluate cranial nerve (CN) function, especially CN I (olfactory), III (oculomotor), IV (trochlear), VI (abducens), and VII (facial). If the patient’s condition permits, also test his visual acuity and gross hearing. Note irregularities in the facial or skull bones as well as swelling, localized pain, Battle’s sign, or face or scalp lacerations. Check for ecchymoses over the mastoid bone. Inspect for hemorrhage or cerebrospinal fluid (CSF) leakage from the nose or ears.
Also, test drainage with a sterile 4" x 4" (gauze pad, and note whether you find a halo sign — > a circle of clear fluid that surrounds the drainage, indicating CSF. Also, use a glucose reagent stick to test clear drainage for glucose. An abnormal test result indicates CSF, because mucus doesn’t contain glucose.
A basilar skull fracture produces raccoon eyes after head trauma that doesn’t involve the orbital area. Associated signs and symptoms vary with the fracture site and may include pharyngeal hemorrhage, epistaxis, rhinorrhea, otorrhea, and a bulging tympanic membrane from blood or CSF. The patient may experience difficulty hearing, a headache, nausea, vomiting, cranial nerve palsies, and an altered LOC. He may also exhibit a positive Battle’s sign.
Raccoon eyes occurring after craniotomy may indicate a meningeal tear and bleeding into the sinuses.
Keep the patient on complete bed rest. Perform frequent neurologic evaluations to reevaluate his LOC. Also, check his vital signs hourly; be alert for such changes as bradypnea, bradycardia, hypertension, and a fever. To avoid worsening a dural tear, instruct the patient not to blow his nose, cough vigorously, or strain. If otorrhea or rhinorrhea is present, don’t attempt to stop the flow. Instead, place a sterile, loose gauze pad under the nose or ear to absorb drainage. Monitor the amount and test it with a glucose reagent strip to confirm or rule out CSF leakage.
To prevent further tearing of the mucous membranes and infection, never suction or pass a nasogastric tube through the patient’s nose. Observe the patient for signs and symptoms of meningitis, such as a fever and nuchal rigidity, and expect to administer a prophylactic antibiotic.
Prepare the patient for diagnostic tests, such as skull X-ray and, possibly, a computed tomography scan. If the dural tear doesn’t heal spontaneously, contrast cisternography may be performed to locate the tear, possibly followed by corrective surgery.
Raccoon eyes in children are usually caused by a basilar skull fracture after a fall.
Read excerpts from these other book chapters related to Eye symptoms:
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1 
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