Battle's sign

Introduction

Battle's sign is a clinical indicator of basilar skull fracture, characterized by bruising over the mastoid process, which is the bony prominence located behind the ear. This sign is named after the British surgeon William Henry Battle, who first described it in the late 19th century. The presence of Battle's sign suggests a significant head injury and necessitates immediate medical evaluation and imaging to assess the extent of the injury and associated complications.

Pathophysiology

The appearance of Battle's sign is due to the accumulation of blood in the postauricular region following a fracture of the base of the skull. The fracture often involves the petrous part of the temporal bone, leading to bleeding from the meningeal arteries or venous sinuses. The blood tracks along the fascial planes and accumulates in the subcutaneous tissues behind the ear, resulting in the characteristic bruising.

Clinical Presentation

Symptoms and Signs

Patients with Battle's sign may present with a variety of symptoms depending on the severity and location of the skull fracture. Common symptoms include:

Headache
Nausea and vomiting
Dizziness
Hearing loss or tinnitus
Cerebrospinal fluid (CSF) otorrhea or rhinorrhea
Facial nerve palsy

In addition to Battle's sign, other physical signs of basilar skull fracture may be present, such as raccoon eyes (periorbital ecchymosis), hemotympanum, and CSF leakage from the nose or ears.

Diagnosis

The diagnosis of Battle's sign is primarily clinical, based on the characteristic bruising behind the ear. However, further imaging studies are essential to confirm the presence and extent of the skull fracture and to identify any associated intracranial injuries.

Imaging Studies

**Computed Tomography (CT) Scan**: A non-contrast CT scan of the head is the imaging modality of choice for evaluating skull fractures. It provides detailed images of the bony structures and can identify fractures, hemorrhages, and other intracranial pathologies.
**Magnetic Resonance Imaging (MRI)**: MRI is useful for assessing soft tissue injuries, brain contusions, and diffuse axonal injury. It is particularly valuable in cases where there is a suspicion of vascular injury or when the CT findings are inconclusive.

Management

The management of patients with Battle's sign involves both supportive care and specific interventions aimed at addressing the underlying skull fracture and any associated complications.

Initial Management

**Stabilization**: Ensure that the patient's airway, breathing, and circulation are stable. Administer supplemental oxygen if needed and establish intravenous access for fluid resuscitation.
**Pain Management**: Administer analgesics to control pain. Avoid medications that can alter mental status, as they may complicate the neurological assessment.
**Neurological Monitoring**: Perform frequent neurological assessments to monitor for any changes in the patient's condition.

Specific Interventions

**Surgical Intervention**: In cases of significant skull fractures with associated intracranial hemorrhage or brain injury, surgical intervention may be necessary. This can include craniotomy to evacuate hematomas or repair dural tears.
**Antibiotic Prophylaxis**: Administer antibiotics to prevent meningitis in patients with CSF leakage.
**Management of Complications**: Address any complications such as intracranial hypertension, seizures, or vascular injuries as they arise.

Prognosis

The prognosis for patients with Battle's sign depends on the severity of the underlying skull fracture and any associated intracranial injuries. Early recognition and appropriate management are crucial for improving outcomes. Patients with isolated Battle's sign and no significant intracranial injury generally have a good prognosis, while those with more severe injuries may have a higher risk of long-term complications and mortality.

References