Synopsis
Recognise clinical and radiological signs of anterior, middle and posterior skull-base fracture, protect the airway and cervical spine, avoid harmful nasal instrumentation, and manage CSF leak, cranial nerve and vascular complications.
- Look deliberately for periorbital ecchymosis without direct eye injury, Battle sign, haemotympanum, clear rhinorrhoea or otorrhoea and cranial nerve dysfunction.
- Basal-skull signs trigger CT head within 1 hour in adults and children under NICE head-injury guidance; plain skull radiography is not an alternative.
- Protect airway and cervical spine, suction orally and use oral rather than blind nasal airway, gastric or tracheal instrumentation when anterior skull-base injury is possible.
- Do not rely on bedside glucose-strip, halo or double-ring testing of fluid; collect a clean sample for laboratory beta-2 transferrin or beta-trace testing if specialist confirmation is required.
- Use CT bone windows and multiplanar review; add high-resolution temporal-bone CT or CT angiography when hearing, facial-nerve or vascular findings create a specific question.
- Manage simple CSF leakage with neurosurgical or ENT observation and avoidance of nose blowing, heavy straining and nasal instrumentation; persistent or complicated leaks need repair planning.
- NICE advises against routine prophylactic antibiotics for basal skull fracture; treat established meningitis promptly and use peri-operative antibiotics only for the relevant surgical indication.
- Document facial movement, hearing, eye movements, vision, gag, palate, shoulder and tongue function because cranial deficits can evolve or be missed during resuscitation.
Key red flags
Periorbital bruising without direct orbital trauma, mastoid bruising, haemotympanum or CSF leakage from nose or ear is a NICE one-hour CT indication for basal skull fracture.
Falling GCS, unequal pupils, seizure, focal weakness or progressive headache and vomiting suggests associated intracranial injury requiring emergency resuscitation and neurosurgical review.
Massive epistaxis, expanding neck signs, Horner syndrome, cranial nerve deficit or stroke symptoms may indicate blunt cerebrovascular injury and requires urgent specialist vascular imaging or intervention.
Investigation priorities
Identify fracture, intracranial haemorrhage, pneumocephalus and mass effect.
Management branches
A basal-skull sign, cranial deficit or high-risk mechanism is identified.
- Run ABCDE with cervical protection, document GCS components and pupils and address airway contamination using oral suction and oral access.
- Avoid blind nasal airway, gastric tube and packing, and arrange non-contrast CT head within one hour under NICE guidance.
- Review CT for intracranial blood, mass effect, pneumocephalus and fracture trajectory and discuss urgent lesions with neurosurgery.
- Add ENT, maxillofacial, ophthalmic or neurovascular input according to hearing, facial, eye, CSF and vascular findings.