Battle's sign
Battle's sign — ecchymosis over the mastoid process of the temporal bone — is commonly the only outward sign of a basilar skull fracture. In fact, this type of fracture may go undetected even by skull X-rays. If left untreated, it can be fatal because of associated injury to the nearby cranial nerves and brain stem as well as to blood vessels and the meninges.
Appearing behind one or both ears, Battle's sign is easily overlooked or hidden by the patient's hair. During emergency care of a trauma victim, it may be overshadowed by imminently life-threatening or more apparent injuries.
A force that's strong enough to fracture the base of the skull causes Battle's sign by damaging supporting tissues of the mastoid area and causing seepage of blood from the fracture site to the mastoid. Battle's sign usually develops 24 to 36 hours after the fracture and may persist for several days to weeks.
History and physical examination
Perform a complete neurologic examination. Begin with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient's level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
Check the patient's vital signs; be alert for widening pulse pressure and bradycardia, signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Also, note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn't. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with basilar skull fracture.
Medical causes
❑ Basilar skull fracture. Battle's sign may be the only outward sign of basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.
Special considerations
Expect a patient with a basilar skull fracture to be on bed rest for several days to weeks. Keep him flat to decrease pressure on dural tears and to minimize CSF leakage. Monitor his neurologic status closely. Avoid nasogastric intubation and nasopharyngeal suction, which may cause cerebral infection. Also, caution the patient against blowing his nose, which may worsen a dural tear.
The patient may need skull X-rays and a computed tomography scan to help confirm basilar skull fracture and to evaluate the severity of head injury. Typically, a basilar skull fracture and associated dural tears heal spontaneously within several days to weeks. However, if the patient has a large dural tear, a craniotomy may be necessary to repair the tear with a graft patch.
Pediatric pointers
Children who are victims of abuse frequently sustain basilar skull fractures from severe blows to the head. As in adults, Battle's sign may be the only outward sign of fracture and, perhaps, the only clue to child abuse. If you suspect child abuse, follow facility protocol for reporting the incident.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Skull deformity
Read excerpts from these other book chapters related to Skull deformity:
Medical Books Excerpts
- Battle's sign
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Battle's sign
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Skull deformity
» Next page: Battle's sign (Professional Guide to Signs & Symptoms (Fifth Edition))
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