Symptoms, diagnosis and treatment of a tumor of the base of the skull

Causes of linear skull fracture

Such a fracture usually occurs as a result of a blow from an object with a large area. Usually there are traces of mechanical impact (abrasion, swelling) above the fracture site.

Skull fractures can be: direct, indirect. With direct impact, the bone is deformed directly at the site of impact; with indirect impact, the impact is transmitted from other damaged bones. Unlike basal skull fractures, vault fractures are direct in most cases.

Mechanogenesis and classification

More often, injuries to the skull and brain occur during road traffic accidents, as well as at work and at home. According to mechanogenesis, the following traumatic brain injuries are distinguished:

1) acceleration injury - diffuse brain damage; 2) impression (local) injury - from blows to the head with an object (counter impact and counter-impact); 3) compression injury.

Morphological changes in the brain are specific to each of these types of injuries and depend on the processes occurring in the cranial cavity.

The mechanical energy acting on the skull wall is transferred to the cerebrospinal fluid and brain tissue rich in water, resulting in complex hydrodynamic phenomena. There are about ten theories of the pathogenesis of traumatic brain injury : the theory of molecular vibrations, displacement of the brain in the cranial cavity, liquor shock, hydrostatic shock, counter-impact of the brain, pressure gradient in the cranial cavity, etc.

Based on the severity of the injury, open and closed injuries of the skull and brain are distinguished. In case of an open injury, the cranial cavity is connected to the external environment through the gap of the calvarial fracture and the soft tissue wound.

Symptoms of a linear skull fracture

A wound or hematoma is found on the scalp, but there is no bone depression felt during palpation.

Common signs of any fracture include:

• Severe headaches;
• Nausea, vomiting;
• Lack of pupillary response;
• Respiratory and circulatory disorders in case of compression of the brain stem;
• Confusion or loss of consciousness.

Features of bone-destructive changes in the temporal bone

The danger of damage to the pyramid of the temporal bone lies in damage to the facial nerve. The consequences of the situation are dangerous: complete loss of taste, hearing, and disruption of the vestibular apparatus. The changes are characteristic of longitudinal bone destructive changes.

CT signs of a temporal bone fracture:

• Hemorrhages inside the pyramid, area of ​​the brain;
• Leakage of cerebrospinal fluid from the ear;
• Violation of the integrity of the eardrum.

With such changes, doctors immobilize the patient's head, since any mobility will lead to hemorrhage in the temporal muscle.

A fracture of the anterior fossa of the skull leads to the leakage of cerebrospinal fluid through the nasal cavity and intranasal bleeding. Symptoms appear on the first day after injury. After three days, the “glasses symptom” appears, in which bluish spots form around the eyes.

The attachment of a fracture of the ethmoid bone cells is accompanied by the accumulation of blood with the formation of bubbles.

Features of damage to the bones of the middle cranial fossa

Bone-destructive changes in the middle fossa of the cranium are diagnosed according to special signs:

• Damage to the eardrum;
• Leakage of cerebrospinal fluid from the ear cavity;
• Unilateral bleeding.

If the facial nerve is affected, loss of hearing, smell, and taste occurs.

Danger of cracks in the posterior cranial fossa

Signs of bone-destructive changes in the area are diagnosed on radiographs and CT scans. The clinical symptoms of a fracture are specific. Accompanied by the appearance of bruises behind the ears. The pathology is accompanied by rupture of the auditory, abducens and facial nerves with life-threatening manifestations. Palate and tongue paralysis are clinical signs of pathology.

Diagnosis of linear skull fracture

To make a diagnosis, the craniography method is used (x-ray examination of the skull without the use of a contrast agent). In some cases, cracks may extend through multiple bones. When studying the images, special attention should be paid to the intersection of the vascular grooves by the crack, since this can damage the intracranial vessels and meningeal arteries, which causes the formation of epidural hematomas. Sometimes the edges of the hematoma can be compacted and raised, which creates the impression of a depressed fracture upon palpation.

Sometimes in medical practice there are mistakes when the shadow of a vascular groove is mistaken for an incomplete fracture (crack). Therefore, it is necessary to take into account the location of the arterial grooves and the specifics of their branches. They always branch in a certain direction, their shadows are not as sharp as fracture lines.

A linear fracture on an x-ray has the following distinctive features:

• The fracture line is black;
• The fracture line is straight, narrow, without branching;
• The vascular groove is gray in color, wider than the fracture line, tortuous, with branching;
• The cranial sutures are gray in color and of considerable width, with a standard course.

8-10 days after a TBI, cracks in the bones are more clearly visible than immediately after the injury.

Injuries to the deep areas of the ear in 50% of cases are combined with damage to other parts of the head and neck. The severity of these injuries depends on the depth of damage to the anatomical structures located in the temporal bone. With longitudinal fractures of the petrous part of the temporal bone, in most cases, a rupture of the eardrum occurs, through which blood and sometimes cerebrospinal fluid flow out. Of particular importance is the combination of an ear wound with penetrating trauma to the bones of the skull and, to an even greater extent, with damage to the meninges and brain matter.

Damage to the dural sinuses can occur with both open penetrating and closed traumatic brain injury. The largest venous sinuses of the dura mater are the superior longitudinal, transverse, sigmoid, as well as the straight and cavernous sinuses [1].

For open wounds and external bleeding from damaged dural sinuses or intracranial hemorrhages, emergency surgical intervention is indicated. It must be accompanied by a full range of measures to compensate for blood loss and stop bleeding as quickly as possible.

Damage to the structures of the posterior cranial fossa accounts for 0.01–0.3% of all traumatic brain injuries [1]. More often, damage to the anatomical formations of the posterior cranial fossa occurs in patients with severe traumatic brain injury, multiple hematomas and brain contusions. They usually occur in car accidents, falls from a height, and direct exposure to a traumatic factor on the occipital region. Rare cases of damage to the structures of the posterior cranial fossa by foreign objects through the external auditory canal and orbit, the development of ischemic damage to the brain stem due to compression of the vertebral and basilar arteries at the site of the clivus fracture by embedded fragments of the occipital bone condyle during its fracture, as well as with atlanto-occipital damage due to compression of the trunk have been described. brain epidural hematoma [2].

In case of injury to the petrous part (pyramid) of the temporal bone, otoscopy usually reveals a fracture of the superoposterior wall of the external auditory canal with a typical stepped protrusion and rupture of the tympanic membrane in the upper quadrants. Subcutaneous emphysema or pulsating hematoma in the mastoid area indicates its damage, in the latter case involving the sigmoid sinus, which is accompanied by severe bleeding from the external auditory canal.

Such clinical cases are rare and anecdotal [3]. We present our own clinical observation.

Patient E.

, 36 years old, was urgently hospitalized in the neurosurgical department of the Kursk Regional Clinical Hospital on January 13, 2016 with a diagnosis of open traumatic brain injury. Otohemolyquorrhea on the right.

From the anamnesis (according to those accompanying him): he was injured on January 13, 2016 at work (a cow gored him in the face), and independently sought help at the ophthalmological hospital with an injury to the eyeball. During the examination, he developed a convulsive seizure with loss of consciousness, fell from his own height, and hit his head on the floor. Delivered to the emergency department of the Regional Clinical Hospital with a laryngeal mask, on artificial ventilation.

The objective condition of the patient upon admission was coma III, Glasgow Coma Scale - 3 points, pulse in the carotid arteries - 40-50 beats/min, weak filling, arrhythmic, blood pressure - 80/40 mm Hg, mydriasis D=S, atony , areflexia, cyanosis of the skin and mucous membranes. He was taken to the emergency operating room, where intensive care was continued. A comprehensive examination was carried out, and an ENT doctor and maxillofacial surgeon were consulted. Fiberglass bronchoscopy and primary surgical treatment of wounds of the left eyelid and mucous membrane of the upper lip were performed. Otohemoliquorhea on the right was noted, the “spot” symptom was positive. Hemodynamics against the background of vasopressor support of adrenaline: pulse 90 beats/min in the carotid arteries, weak filling, blood pressure - 90/60 mm Hg, with an increase in hemodynamic parameters, heavy bleeding was noted from the external auditory canal, an aseptic bandage was applied. A computed tomography scan of the brain was performed: a linear fracture of the petrous part of the temporal bone, passing through the sigmoid sinus, the canal of the internal carotid artery, the walls of the external auditory canal; no volumetric effect on the brain was detected, the basal cisterns were not deformed (see figure).

Computer tomogram of the pyramids of the temporal bones of patient E. (axial projection, “bone window” mode). The arrows indicate the fracture line passing through the groove of the sigmoid sinus (1), the walls of the external auditory canal (2), the canal of the internal carotid artery (3), the occipital bone (4), the upper edge of the pyramid of the temporal bone (5).

The patient was transported to the intensive care unit; due to heavy bleeding, an additional aseptic bandage was applied and digital pressure was applied to the common carotid artery on the right. A repeat consultation with an ENT doctor was scheduled. Profuse bleeding from the external auditory canal has intensified, an injury to the lower wall of the external auditory canal is detected, the eardrum is dark blue in color.

On January 13, 2016 at 9:40 p.m., the patient was admitted to the intensive care unit in extremely serious condition. Resuscitation measures were continued, coma III was observed, Glasgow Coma Scale was 3 points, hemodynamics were maintained with increasing doses of adrenaline. Atony, areflexia. Pupils dilated D=S, photoreaction abs.

During intensive therapy, the patient's condition did not improve, multiple organ failure progressed, and heavy bleeding from the external auditory canal continued. At 22.30, despite resuscitation measures, cardiac arrest occurred.

Final diagnosis: the underlying disease is an open craniocerebral injury. Fracture of the bones of the vault and base of the skull with damage to the sigmoid sinus, jugular vein and internal carotid artery in the canal of the temporal bone pyramid. Moderate brain contusion. Otohemolyquorrhea on the right. Massive bleeding from the external auditory canal. Episyndrome. Left paraorbital hematoma. Bruised wounds of the upper left eyelid, mucous membrane of the upper lip. Coma III."

Complication of the underlying disease: grade IV hemorrhagic shock.

The given clinical observation is a rare and severe pathology that a practicing otorhinolaryngologist may encounter.

The authors declare no conflict of interest.

1e-mail; orcid: https://orcid.org/0000-0001-5447-7523