Basilar skull fracture lias four classic signs:

1. Raccoon eyes: periorbital ecchymosis

2. Battle's sign: postauricular ecchymosis

3. Hemotympanurn: blood behind the eardrum

4. Cerebrospinal fluid otorrbea/rhinorrhea: clear fluid from the ear's or nose Important points:

1. Skull fractures of the calvarium are seen on CT scan (preferred) or x-ray, generally as a depressed fracture. Surgical indications are contamination (cleaning and debridement), impingement on. brain parenchyma, or open fracture with cerebrospinal fluid leak. Otherwise, fractures may be observed and generally heal on their own.

2. Head trauma also may cause cerebral contusion or shear injury of the brain parenchyma. Neither may show up on a CT scan, but both may cause temporary or permanent neurologic deficits.

Increased intracranial pressure (intracranial hypertension): normal intracranial pressure is 5-15 mrnHg). An increase is suggested by bilaterally dilated and fixed pupils. Other symptoms include headache, papilledema, nausea and vomiting, and mental status changes. Look also for the classic and important Cushing's triad (increasing blood pressure, bradycardia, respiratory irregularity). The first step is to put the patient in reverse Trendelenburg (head up) and intubate. Once intubated, the patient should be hyperventilated to rapidly lower the intracranial pressure. This approach decreases intracranial blood volume by causing cerebral vasoconstriction. If the decrease in pressure is not sufficient, mannitol diuresis can be tried to lessen cerebral edema. Furosemide is also used but less effective. Barbiturate coma and decompressive craniotomy (burr holes) are last-ditch measures. Prophylactic anticonvulsants are controversial.

■ Cerebral perfusion pressure equals blood pressure minus intracranial, pressure. In other words, do not treat hypertension initially in a patient with increased intracranial pressure; hypertension is the body's way of trying to increase cerebral perfusion.

■ Never do a lumbar tap on any patient with signs of increased intracranial pressure until a CT scan is done first. If the CT is negative, you can proceed to a tap, if needed.

Spinal cord trauma; often, presents with spinal shock (loss of reflexes, loss of motor function, and hypotension). Get standard trauma .x-rays (cervical spine, thorax, pelvis) as well as additional spine x-rays based on physical exam. Also give steroids (proved to improve outcome). Surgery is done for incomplete neurologic injury (some residual function is maintained) with external compression (e.g., subluxation, bone chip).

Spinal cord compression.: subacute, compression (vs. acute compression in trauma) is often due to metastatic cancer but also may be due to a primary neoplasm or subdural or epidural abscess or hematoma (especially after lumbar tap or epidural/spinal anesthesia in a patient with a bleeding disorder or on anticoagulation). Patients present with local spinal pain (especially with, bone metastases) and neurologic deficits below the lesion (hyperreflexia, positive Babin ski's, weakness, sensory loss). The first steps in the emergency department are to give high-dose corticosteroids and get a CT/MRI. Then give radiotherapy to metastases from a known primary that is radiosensitive. Alternatively, surgical decompression may be done.

■ Prognosis is most closely related to pretreatment function; the longer you. wait to treat;, the worse the prognosis.

■ For hematoma or subdural/epidural abscess (seen especially in diabetics and usually due to Staphylococcus aureus), surgery is indicated for decompression and drainage.

Syringomyelia: central pathologic cavitation of the spinal cord, usually in the cervical or upper thoracic region. Syringomyelia is idiopathic but may follow trauma or congenital cranial base malformations (e.g., Arnold-Chiari or Dandy-Walker syndrome).The classic presentation is a bilateral loss of pain and temperature sensation below the lesion in the distribution of a "cape" due to involvement of the lateral spinothalamic tracts. The cavitation in the cord gradually widens to involve other tracts, causing motor and sensory deficits. MRI is the imaging study of choice, and treatment is surgical (creation of a shunt).

Neural tube defects: triangular patch of hair over the lumbar spine indicates spina bifida occulta. More serious defects are obvious and occur most commonly in the lumbosacral region. Meningocele is defined as meninges outside the spinal canal; myelomenigocele, as central nervous system tissue plus meninges outside the spinal canal. Most importantly, giving folate to potential mothers reduces the incidence of neural tube defects.

Hydrocephalus: in children, look for increasing head circumference, increased intracranial pressure, bulging fontanelle, scalp vein engorgement, and paralysis of upward gaze. The most common causes include congenital malformations, tumors, and inflammation (hemorrhage, meningitis). Treat the underlying cause, if possible; otherwise, a surgical shunt is created to decompress the ventricles.

Bell's palsy: most common cause of facial paralysis; sudden unilateral onset, usually after an upper respiratory infection.The cause is unknown but may be viral, immune, or ischemic. Patients may have hyperacusis; everything sounds loud because the stapedius muscle in the ear is paralyzed. In severe cases, patients may be unable to close the affected eye; use drops to protect the eye. Most cases resolve? spontaneously in about 1 month, although some have permanent sequelae.

Other causes of unilateral facial paralysis:

^ Herpes (Ramsay Html: syndrome): eighth cranial nerve is commonly involved also. Look for vesicles on pinna and inside ear, encephalitis and meningitis may be present.

m Lyme disease: probably the most common cause of bilateral facial nerve palsy. m Middle ear and mastoid infections a Meningitis m Iracmre (temporal bone): patients may have battle's sign and/or bleeding from the ear. m Tumor: especially in the cerebelloponline angle (acoustic neuroma; consider neurofibromatosis) or glomus jugulare.

Note: Get CT/MRI scans of the head to evaluate if the cause is not apparent or seems suspicious (especially if additional neurologic signs are present ) after history and/or physical exam.

Hearing loss: the most common cause is aging (presbycusis); a hearing aid can be used, if needed. History may suggest other causes:

h Exposure to prolonged or intense loud noise m Congenital TORCH infection m Meniere's disease: accompanied by severe vertigo, tinnitus, nausea and vomiting; treated with anticholinergics, antihistamines (meclizine), or surgery (if refractory)

m Drugs (aminoglycosides, aspirin, quinine, loop diuretics, eisplatin)

m Tumor (usually acoustic neuroma).

m labyrinthitis: may be viral or follow/extend from meningitis or otitis media ¡a Diabetes mellitus « I ly pothyroidisrn m Multiple sclerosis m Sarcoidosis a Pseudotumor cerebri

Sudden deafness: develops over a few hours; most often due to a viral cause (endolymphatic labyrinthitis from mumps, measles, influenza, chickenpox, adenovirus). Hearing usually returns within 2 weeks, but Joss may be permanent. No treatment has proved effective; empiric steroids often are used.

Note: Bacterial meningitis is the most common cause of acquired hearing loss in children. Follow all children with hearing testing after a bout of meningitis.

Vertigo: may be due to the same eighth cranial nerve lesions that cause hearing loss (Meniere's disease, tumor, infection, multiple sclerosis). Another common cause is benign positional/paroxysmal vertigo,which is induced by certain head positions and may be accompanied by nystagmus without associated hearing loss.The condition often resolves spontaneously; treatment is not necessary,

Note: Deviated nasal septum or other congenital defects may cause recurrent sinusitis. Treat with surg i cat correction.

Causes of rhinitis (edematous, vasodilated nasal mucosa and turbinates with clear nasal discharge):

1. Viral (common cold): iron) rhinoviru.s (most common), influenza, parainfluenza, cox-saclde virus, adenovirus, respiratory syncytial virus, coronavirus, echovirus. Treatment is symptomatic; vasoconstrictors such a phenylephrine are used for short-term treatment but may cause rebound congestion.

2. Allergic (hay fever): associated with seasonal flare-ups, boggy and bluish turbinates, early onset (< 20 years old), nasal polyps, sneezing, pruritis, conjunctivitis, wheezing, asthma, eczema, positive family history, eosinophils in nasal mucus, and elevated IgE. Skin tests may identify an allergen. Treat with avoidance when the antigen (e.g., pollen) is known, antihistamines, cromolyn, and/or steroids for severe symptoms. Desensitization is also an option.

3. Bacterial infection: from Streptococcus A, Pneumococcus, or Staphylococcus spp. Do streptococcal throat culture, and treat with antibiotics if appropriate (sore throat, fever, tonsillar exudate).

The most common cause of nosebleed in children is nose-picking (trauma), but watch out for local tumor, leukemia, and other causes of thrombocytopenia (idiopathic thrombocytopenic purpura, hemolytic uremic syndrome). Nasopharyngeal angiofibroma should be suspected in adolescent males with recurrent nosebleeds and/or obstruction but no history of trauma or blood dyscrasias. Leukemia may result in pancytopenia; look for associated fever and anemia.

Neck mass:

1 75% are benign in children, and 75% are malignant in patients > 40 years old. 2. Causes:

h Branchial cleft cysts: lateral; often become infected. n Tliyroglossal duct: cysts: midline; elevate with tongue protrusion. m Cystic hygroma: lymphangioma; treat with surgical resection.

«Cervical lymphadenitis: from streptococcal pharyngitis, lipstein--Barr virus (commonin adolescents and adults in 20s), cat-scratch disease, Mycobacterium sp. (scrofula).

»Neoplasm: may be lymphadenopathy due to primary (lymphoma) or metastatic neoplasm, or the mass may be the tumor itself.

3, Work-up of unknown cancer in the neck includes random biopsy of the nasopharynx, palatine tonsils, and base of the tongue as well as laryngoscopy, bronchoscopy, and esopha goscopy (with biopsies of any suspicious lesions)—the so-called triple endoscopy with triple biopsy.

Otitis externa (swimmer's ear): most commonly due to Pscudoinomis aeruginosa, Manipulation of the auricle produces pain; the skin of the auditory canal is erythematous and swollen. Patien ts may have foul-smelling discharge and conductive hearing loss. Treat with topical antibiotics (neomycin, polymyxin R); steroids may reduce, swelling.

Otitis media: .most commonly due to Streptococcus pneiunoniac, Haemophilus influenzae, and .Momxelia ca-larrhalis. Manipulation of the auricle produces no pain. Patients have earache, fever, erythematous and bulging tympanic membrane (light reflex and landmarks are difficult to see), and nausea and vomiting. Complications include tympanic membrane perforation, (bloody or purulent discharge), mastoiditis (fluctuation and inflammation over mastoid process 2 weeks alter otitis), labyrinthitis, palsies of cranial nerves VII and VIII, meningitis, cerebral abscess, lateral sinus thrombosis, and chronic otitis media (permanent perforation of tympanic membrane). Patients may get cholesteatomas with marginal perforations; treat with surgical excision. Treat otitis with antibiotics to avoid these complications (amoxicillin, second-generation cephalosporins such as cefuroxime or trirnethopriiii--sulfame.thoxa7.ole).

■ Recurrent otitis media is a common pediatric clinical problem (as well as prolonged secretory otitis, a result of incompletely resolved otitis) and can cause hearing loss with resultant developmental problems (speech, cognitive functions). Treatment consists of prophylactic antibiotics or tympanostomy tubes. Adenoidectomy is thought to help in some cases by preventing blockage of the eustachian tubes.

■ Infectious myringitis (tympanic membrane inflammation) is caused by Mycoplasma sp., Streptococcus pneumoniae, or viruses. Otoscopy reveals vesicles on the tympanic membrane. Treat, as otitis media (with antibiotics).

Sinusitis: often due to S. pneumoniae, H. influenzae, and other streptococci or staphylococci. Look for tenderness over affected sinus, headache, and purulent nasal discharge (yellow or green). X-ray shows opacification of the sinus; CT is used to evaluate chronic sinusi tis or suspected extension of infection outside the sinus (suggested by high fever and chills). Treat with antibi otics (penicillin/amoxicillin or erythromycin for 2 weeks, up to 6 weeks for chronic cases), Operative intervention for resistant cases (drainage procedure, sinus obliteration). Remember that the frontal sinuses are not well developed until after the age of 10 years.

Otosclerosis: the most common cause of progressive conductive hearing loss in adults (vs. presbyacusis, the most common cause of sensorineural hearing loss in adults). Otic bones become fixed together and impede hearing. Treat with hearing aid or surgery.

Parotid swelling: the most common cause is mumps.The best treatment for mumps and the complication of infertility is prevention through immunization. Parotid swelling also may be due to neoplasm (pleomorphic adenoma is the most common), Sjogren's syndrome, sialolithiasis (more common in the submandibular gland), and sarcoidosis.

Note: After nasal fracture (which you should be able to recognize on x-ray), rule out a septal hematoma, which, must be removed to prevent pressure-induced septal necrosis.

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