Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture

Clinical Features and Management of Skull Base Fractures in the Pediatric Population: A Systematic Review

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

The Observation of Pediatric Skull Fractures Without an Associated Brain Injury in a Non-Trauma Center

Introduction Young children experiencing head trauma are prone to skull fractures. Pediatric skull fractures are distinct from adults as they have a greater capacity to undergo remodeling. The objective of this study was to evaluate whether children with isolated skull fractures without an underlying brain injury and normal neurological exam require a transfer to a tertiary hospital with pediatric neurosurgery service. Methods A retrospective chart review was performed to review children under five years old presenting to the emergency department of a non-pediatric trauma center with an isolated skull fracture resulting from head trauma without intracerebral hemorrhage between 2015 and 2021. The inclusion criteria consisted of children who have isolated skull fractures without underlying injuries and normal neurological examination. We reviewed these patients' injury characteristics, disposition, and clinical outcomes. The t-test and chi-square were used for evaluating the groups and evaluating the transfer to a dedicated trauma care facility. Results We identified 26 children who had isolated skull fractures with no underlying brain injury and normal neurological examination. The two most common mechanisms of injury were falls (64%) and motor vehicle collisions (MVC) (11%). The median age of patients was six months old. The location of the skull fractures was as follows: parietal (46%), occipital (19%), temporal (15%), frontal (7.7%), occipital + parietal (7.7%), and parietal + frontal (3.8%). Four fractures were depressed (15%) and the remainder were non-displaced. Eleven children with skull fractures (42%) were transferred to a designated pediatric trauma center and the remaining 58% were hospitalized for observation and monitored at the primary hospital. None of the children with skull fractures required intubation or other advanced interventions. Conclusion In this relatively limited sample, approximately one-third of the children with isolated skull fractures without brain injury were managed successfully in a non-tertiary care center. However, none of them required surgical intervention. Thus, we propose that patients akin to those in this study can be observed at a local hospital without being transferred to a pediatric trauma center.

Pediatric basilar skull fractures from multi-level falls: A systematic review and retrospective analysis

OBJECTIVE

Multi-level fall (MLF) accounts for 26.5%-37.7% of traumatic pediatric basilar skull fractures (BSFs). There is a dearth of information concerning recommendations for work-up, diagnosis, treatment, and otolaryngological follow-up of pediatric basilar skull fractures secondary to MLFs. Through a systematic literature review and retrospective review of an institution's trauma experience, we sought to identify clinical findings among pediatric MLF patients that indicate the need for otolaryngological follow-up.

METHODS

A two-researcher team following the PRISMA guidelines performed a systematic literature review. PubMed, Web of Science, and EBSCO databases were searched August 16th^, 2020 and again on November 20th^, 2021 for English language articles published after 1980 using search terms Pediatric AND (fall OR "multi level fall" OR "fall from height") AND ("basilar fracture" OR "basilar skull fracture" OR "skull base fracture" OR "skull fracture"). Simultaneously, an institutional trauma database and retrospective chart review was performed for all patients under age 18 who presented with a MLF to a pediatric tertiary care center between 2007 and 2018.

RESULTS

168 publications were identified and 13 articles reporting pediatric basilar skull fracture data and MLF as a mechanism of injury were selected for review. MLF is the most common etiology of BSF, accounting for 26.5-37.7% of pediatric BSFs. In the retrospective review, there were 180 cases of BSF from MLF in the study period (4.2%). BSF and fall height were significantly associated (p < 0.001), as well as presence of a CSF leak and fall height (p = 0.02), intracranial hemorrhage (ICH) (p = 0.047), and BSF fracture type (p < 0.001). However, when stratified by age, these associations were only present in the younger group. Of those with non-temporal bone BSFs (n = 71), children with hemotympanum (n = 7) were approximately 18 times more likely (RR 18.3, 95% CI 1.89 to 177.02) than children without hemotympanum (n = 64) to have hearing loss at presentation (28.6% vs. 1.6% of patients).

CONCLUSIONS

MLF is the most common cause of pediatric basilar skull fractures. However, there is limited information on the appropriate work-up or otolaryngologic follow-up for this mechanism of injury. Our retrospective review suggests fall height is predictive for BSF, ICH, and CSF leak in younger children. Also, children with non-temporal bone BSFs and hemotympanum may represent a significant population requiring otolaryngology follow-up.

[Skull and skull base injuries in children and adolescents : Results of a monocentric analysis]

BACKGROUND

The present study comprises a retrospective analysis of skull, skull base, and midface fractures in children, to provide clinical orientation for their management. To date, only few data are available on these injuries in this patient group.

METHODS

Data from inpatient cases diagnosed with a midface, skull, or skull base fracture in the Children's Hospital Auf der Bult from 2015 to 2020 were evaluated. Age, gender, fracture mechanism, diagnosis, treatment, and possible complications were analyzed. Data of 224 children were grouped into 107 cases with nose fractures, 104 cases with skull fractures, 9 patients with temporal bone fractures, 4 patients with rhinobasal fractures, and 2 cases with fractures of the orbital floor.

RESULTS

Among patients with nose fractures, the average age was 10.9 years (64% males), among patients with skull fractures 1.0 year (64% males), and in children with skull base fractures 6.0 years (85% males). Falls were the most frequent genesis (63%), followed by car accidents, collisions (25%), and violence (10%). Patients with skull fractures underwent sonography in 94% of cases; in 87% the fracture was verified. Patients with nose fractures underwent x‑ray in 92% of cases, or sonography only in 8%; 95% of patients with nose fractures underwent operative repositioning. Typical fracture signs (i.e., hemotympanum, ophthalmic symptoms) or signs of central nervous system involvement (i.e., nausea, amnesia) occurred in 12 of 13 children with skull base fractures, and CT was performed in all these cases (none of whom developed a cerebrospinal fluid leak).

CONCLUSION

The imaging modality should be selected based on the clinically suspected diagnosis and the course. Most fractures can be sufficiently treated without any permanent sequelae, except for nose fractures, which frequently require operative repositioning.

Infectious Meningitis and Encephalitis

Infectious meningitis and encephalitis are associated with significant morbidity and mortality worldwide. Acute bacterial meningitis is rapidly fatal and early recognition and institution of therapy are imperative. Viral meningitis is typically a benign self-limited illness. Chronic meningitis (defined as presenting with >4 weeks of symptoms) is most often caused by tuberculosis and fungal infection. Because the diagnostic testing for tuberculous meningitis is insensitive and cultures often take weeks to grow, therapy is often initiated empirically when the diagnosis is suspected. Human simplex virus encephalitis is the most common cause of encephalitis and requires prompt treatment with intravenous acyclovir.

Biomechanical analysis of skull trauma and opportunity in neuroradiology interpretation to explain the post-concussion syndrome: literature review and case studies presentation

Traumatic head injuries are one of the leading causes of emergency worldwide due to their frequency and associated morbidity. The circumstances of their onset are often sports activities or road accidents. Numerous studies analysed post-concussion syndrome from a psychiatric and metabolic point of view after a mild head trauma. The aim was to help understand how the skull can suffer a mechanical deformation during a mild cranial trauma, and if it can explain the occurrence of some post-concussion symptoms. A multi-step electronic search was performed, using the following keywords: biomechanics properties of the skull, three-dimensional computed tomography of head injuries, statistics on skull injuries, and normative studies of the skull base. We analysed studies related to the observation of the skull after mild head trauma. The analysis of 23 studies showed that the cranial sutures could be deformed even during a mild head trauma. The skull base is a major site of bone shuffle. Three-dimensional computed tomography can help to understand some post-concussion symptoms. Four case studies showed stenosis of jugular foramen and petrous bone asymmetries who can correlate with concussion symptomatology. In conclusion, the skull is a heterogeneous structure that can be deformed even during a mild head trauma.

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

OBJECTIVE

Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.

METHODS

The authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.

RESULTS

The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).

CONCLUSIONS

The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

Neuromuscular electrical stimulation on hearing loss caused by skull base fracture: A protocol for systematic review of randomized controlled trial

BACKGROUND

This systematic review aims to investigate the effectiveness and safety of neuromuscular electrical stimulation (NMES) on hearing loss (HL) caused by skull base fracture (SBF).

METHODS

We will retrieve the following electronic databases of Cochrane Library, PUBMED, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from the inception to January 1, 2019 for relevant RCTs of NMES for HL caused by SBF. Two experienced authors will independently perform the study selection, data extraction, and methodology quality assessment. A 3rd author will solve any disagreements between 2 authors through discussion.

RESULTS

This study will provide a high-quality synthesis of latest evidence of NMES for HL caused by SBF from comprehensive assessments, including hearing loss evaluation, hearing threshold, quality of life, and any relevant adverse events.

CONCLUSION

The expected results of this systematic review will provide the up-to-date evidence to assess the effectiveness and safety of NEMS for patients with HL caused by SBF.

ETHICS AND DISSEMINATION

The results of this study will be disseminated through publication in a peer-reviewed journal or will be presented at an associated conference meeting. This study will not use individual patient data, thus, the ethical approval is not needed.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019120195.