Basilar Skull Fracture - Possible CSF Leak

[Mr. J.]

Hello,

Eleven days ago I suffered a sports closed-head injury. I apparently hit two different parts of my head. The orbit around my right eye was broken in two places and I had a classic racoon eye. Then, on the left side of my head I received a basilar skull fracture (the temporal area), two small brain hemmorhages, and a small neumocephallus. All fractures non-displaced. In the ER, a CT-scan was done which showed these injuries. The next day another CT-scan showed fluid had developed in my left mastoid and my left middle-ear. The injury happened 11 days ago now and the left ear discomfort/pressure/pain continues. It is worse when I get up in the morning than during the day. I am very concerned about a CSF leak but do not have any obvious dripping - just the ear discomfort. My questions:

1) In the hospital, the neurologist thought the fluid seen on CT-scan was CSF. A different neurosurgeon last week said without dripping it probably was not CSF and he was not concerned. Does this sound likely that it is not CSF? From my research, a basilar skull fracture, neumocephallus, and fluid in the mastoid and middle ear all point towards CSF! Can there be another explanation for this fluid?

2) I'm concerned about CSF leak into my ear. Are my concerns justified? What should I do at this point to address this concern? What tests are needed?

3) Is the neumocephallus something that should be addressed with further scans or treatment? It was described as "small" and "tiny" and "minimal" on my scans.

4) What are my meningitis chances? How can I protect myself?

Thanks.

[Demiguise]

You're right on all things mentioned. We can all get ear fluid
if eustachian tubes act up , swell, the fluid sucks up into
middle ear like a straw. When normal, that moisture is absorbed
into upper cell wall & then dries out. Your problem is complexed
so it's a rule out game. With no leak, only other tests would be LP or open & culture ear. George Clooney fell out of a chair
in a film last yr. Dull hdache & a slt nose drip off/on for 2
wks finally got him to the right doc. He injured his neck & they
focused on that. They did an LP & a slt nasal collection that
showed transferrin. It was an almost sealed leak but they went in & did a patch. He now can't get rid of off/on migraines.
Glad to read you're your own advocate. It will get figured out
eventually. I feel like you owe me a drink for Net dating! Get
back later when ya' have the answer. Will help broaden my
education! Gd-luck.

[Mr. J.]

Thanks for your additional thoughts.  I have made appointments again with both the neurosurgeon and the ENT.  I am really convinced there is fluid in my ear - the only question is "What kind of fluid?"  If I cannot get any to drip out of my nose or my ear, I'm not sure how they will find out what kind of fluid it is.

Thanks for your link on that Iran study.  Actually, I had already run across that one (I've been doing a lot of surfing on this stuff the last week).  From what I've been reading, studies to date have not shown a conclusive benefit from the use of antibiotics to prevent post-traumatic menengitis.  And some believe that the use of the antibiotics may help to develop drug-resistant strains of bacteria so if/when you get meningitis you will have a really bad strain.

Actually, the "other guy" is the ground!  I did run into another person head-to-head but it was the back of his head so he did not get hurt (doc said back of the skull is thicker but I bet you knew this already).  But after I knocked heads with him I apparently blacked out momentarily and then fell to the ground where I smashed the other side of my head (and received the skull fracture).  So, it was the ground that did more damage than my opponent.  At least, that is how I think it happened but I'm not totally sure to be honest.

Thanks for your help.  Have a great day....

[Mr. J.]

Thanks for your thorough response.  I wanted to respond to a few of your comments/questions.  I maybe lost conciousness for just a few seconds but it was very brief.  It has been nearly two weeks now and I am feeling better all the time but the pressure in that one ear is still driving me crazy - mostly in the mornings.  I'm sorry, I think I spelled the word wrong - I believe it is "pneumocephalus" which is an air bubble inside the skull.  The fracture around my eye was in the "orbit" - at least that is my understanding.

As far as the fluid is concerned, when I was in the hospital the neurologist there speculated that the fluid was cerebral spinal fluid.  But after being discharged both my primary care physician and a neurosurgeon are saying it is not cerebral spinal fluid because I have no obvious leaking/dripping.  Instead, as you mention, I think they believe the fluid is due to edema or blood from the injuries.  I just want some peace of mind on this - in the unlikely event it is CSF I do not want to sit around just waiting to get meningitis.  I guess there are some tests they can do where they inject a tracer into your spine and then wait and see if it shows up anywhere other than your spine or your brain - at least that is my limited understanding at this point.

No, I did not have any appreciable hearing loss.  I still get some ringing in my ears.  I also saw an ENT Dr. who said that the fracture went part way through a bone next to my ear and that if it had gone all the way through I would have become deaf in that ear - but I was fortunate.

I am torn as far as what to do at this point.  I do not live in a large community and so my options are somewhat limited as far as what doctors I can see with my insurance.  I am thinking I will go back and see the neurosurgeon again but am wondering if maybe the ENT would be the way to go too!?

You sound like you have some medical training?  Or are you like me and have done enough internet surfing that you know just enough to be dangerous!  LOL

Thanks again for your responses. Have a great day....Mr. J.

[Demiguise]

You didn't mention how the other guy looks? Or maybe you just
weren't looking. Thought you meant pneumocephalus but then alot
of neurotics race to Dr & drive them over the edge. My brother
fractured a finger & drove Dr crazy now that he's a cripple! It
was very funny to me. Not MD but retired from education in
physiology. (What connects to what to make response). I offer my
help when I read frustration & you can run w/ it to Dr. I can
shrink dwn the problem for direction but the MD's have to locate
& dx. I have a following of young-ones here that may soon pounce
on your post. Know it all/wanna be/wow, knows the Net! Just a
few blasts! Net is a great tool but if ya' don't know the whole
circuit board, most think 'I've got it'! Impending death! You
sound normal. Your head was cracked & your focus is on the
prevention of infection. Stay w/ ENT awhile. He knows how to
read films like neuro. Can tell w/ comment abt fracture. Further
would cause hearing loss means the crack was at the Trigeminal
Nerve site (CNV). Tri=3 branches, up=head/over=to eye-sinuses/
dwn=to ear-jaw-mastoid area. It stopped near 'inner ear',hearing
compartment. You got lucky! There are extended branches from this nerve that were poss. damaged & transmission is mixed msg.
Just a guess. Personal experience! Autonomic function may be in
a gliche & time may correct. From here on, alot is clinical
eval. Like 'Coronal CT' to ck sinuses w/ poss trapped fluid
that was missed causing 'eustachian tube' inflamm. & ck mastoid
cells. If a wire gets spliced, no power. Same w/ nerves. The
ck for Serous fluid will rule out things. Orbit-fracture means
the bones/facial/socket near eye. An orbit can't fracture. It's
your eyeball. The pladgets for csf is generally insert in nose
to detect immediate drip to analyze w/o air exposure. If your
nose is dry (no chronic drip) ENT wouldn't put you through. Ear
ringing could be from meds/trauma settling/maybe fluid in ear
shifting like a carpenters level. Inner ear fibers do this. Ear
prob. is the most illusive thing to dx. A close bound w/ ENT
will get you help & referrals when necessary. Bilateral would
send you between Dr's. Unilateral, stay w/ ENT. Coronal scan is
a 'nose-in & on stomache scan'. Face up CT won't detail ear/
sinuses as well. Antibiotics are given if signs of meningitis
are present within 7 days. Maybe discuss anxiety w/ ENT & he'll
consider a prophylactic approach. 'The in-case', give rx. Prob.
may lower immune short time. Get med records from hospital and
read what you were IV'd w/. May have been addressed already.
Your Dr can order a MRI w/ gad-dye to detail & ck brain flow of ventricles. An upset at that point can hint pressure problem &
that is often what triggers chronic hdache. Many leaks seal on there own w/ a week of bedrest. Get tests w/ ENT soon so ear
function can be forced to operate & effusion can't happen. The
clearing of prssr can be done manually by valsalva, but DON'T
do till ENT can OK. This can push prssr/fluid into mid-ear or raise csf prssr in head. Laying w/ moist hot compress to temple
can help while laying on gd-ear side. Ck BP too. Artery flow
can trip this ear condition & affect small vessels feeding info. I'm in a big city w/ resources. Sometimes small town is better. I'll ad a google that's recent & can give you some info
on a study that sort-of relates. Use quotes & + exact. Print &
maybe share w/ Dr. I'll be around & ck back. Gd-luck.
"prophylactic antibiotic"+csf+pubmed then click on 1st article.
Hate to support Iran articles but this was a gd-study. If in US
some treatments/terms differ from NH-care countries.(UK/NZ).
Aren't you lucky you have a thick skull!

[Demiguise]

1st ?, how are you? Must have been quite a head-crash. Did you
lose conscious? Do you have daily headaches or any dizzy? It
reads like you've done some hm-wk. I'm seldom stumped, so could
you tell me what neumocephallus is? Haven't heard it before nor
can I find in any book? Strange. Any way The CT read depends on
the knowledge of reader/location of points/dx's etc. Sounds like
you have a copy. The skull must take quite an impact to fracture
like you describe but it actually is prone to crack w/ fissures longitude or linear. A Basilar Skull Fracture usually starts at
skull-base & can go linear to temple. Only Neuro really looking at films can tell what's being affected. Location means alot.
Did you mean rt-orbit or 'socket'? A severe csf leak w/ fracture
usually gives 2 racoon eyes but who knows. CSF is in a soft
tube starting at spine base covering it & flowing up to skull & then around brain. The brain is protected by this & brain will
float if jolted against the meningeal cover & bounce from skull.
Then you have muscle/tissue between that to scalp. Oddly, we are
sent hm. wondering. Skull fractures can fill in & thats it. The
brain can get bruised/trauma but settle & we can be fine. The
key is for Dr to see if lobes have had trauma to nerves. Films
don't tell all. Clinical observation helps. The left temple has
2 hemorrhages from fracture/no mastoid fluid. 2nd CT HAS fluid
so both scans need to be re-looked to confirm. Swelling/edema/
inflammation could explain. The trigeminal nerve has 3 branches
& could spasm affecting the 'inner' ear that can cause a type
sweating in middle ear. That same nerve has stems that go to
mastoid cells that may be showing trapped drainage & not csf leak. After 11 days, pressure/pain, I'd consider ck'g out all
films to take to a Neuro-Otologist. Fractures were non-displaced. That's a good. I guess no hearing loss, good! No
fluid leaking out nasal is good. CSF is made fresh & replaced
3xday. Besides your problems, you really should be having a bad
hdache if a leak, even walking upright. Night swelling is common so it makes sense mornings are bad till gravity gets fluid flowing better. The odds of meningitis is poss. but slim
since no infection of mention w/ trauma. Infection would more
likely show w/ ear by now. You print fine except wrong board
like you said. Maybe a little brain gliche you're entitled to!
It takes time for your jolt to settle. If not having any Neuro
symptoms then a ENT "Otolaryngologist" can even ck ear w/ light
through tympanic window for fluid or do quick test for 'Serous-
fluid' by putting in a plug that sucks fluid to window & prints
out result. Takes 5min. I had a yr. of ear pressure from a
sinus condition so I had ENT open window/draw sm. amt fluid/put
in a eartube to dry out & relieve pressure. Fluid was tested for (beta-2-transferrin)1 type CSF test. Tube fell out in 6 wks. Fine until a sinus problem swelled tissue that tripped inner ear closest to temple area & pressure returned. I'm very
glad you're OK. I would do a fol-up w/ your own Dr & maybe get
a referral to? A fol-up w/ a 'Coronal CT' would detail Mastoid more & your Dr can order that. Spasms cause fluid inflammation
that may re-absorb. If you have ear pain, you need to fol-up.
There is another condition called a 'fistula' that does pressr
but hard to dx till other stuff is ruled out. Yes you are
justified w/ concern since you're not sure if it's neuro-spasm
or ear problem. Just doesn't sound like CSF leak but time will
tell. Eventually you'd have the worse migraine & they would do
a LP & ck level. You just read 'War & Peace'! How's the other
guy?

[Mr. J.]

Hello,

I am very sorry.  I thought I was posting a question to the doctor but apparently posted to the wrong forum.  And I did so twice too - how embarrasing!  Well, I will keep trying to get a question through to the doctors but until then if anyone can provide any insight into my issues, I'd love to hear from you.

Thanks...Mr. J.