Hot Seat #167: The Slippery Slope of Head Trauma

Posted on: March 4, 2021, by :

Tim Carr, MD


14 year old previously healthy male presenting after hitting his head on a tree 1 hour prior to arrival. Patient was sledding on a steep embankment an hour prior to arrival when he lost control catching the right side of his head on a tree three-quarters of the way down the hill. Episode was witnessed by mother at the top of the hill who states he did not hit any other area of his body. He did not lose consciousness and was mentating normally at the scene. Patient had no complaints when he got home besides mild soreness to right side of his head on palpation and mild “ear popping” to his right ear. He did have one episode of NBNB emesis shortly thereafter.

At outside ED, vitals were within normal limits and patient was mentating appropriately with no focal neurologic deficits on exam. HEENT exam notable for tenderness and abrasion around the right mastoid process but no documented bruising concerning for Battle sign. No other documented cranial deformities or signs of basilar skull fracture. No other areas of tenderness, bony stepoffs or deformities on exam and no concern for thoracic or abdominal trauma. The ED physician consults the Children’s MCO by phone.

Due to presumed mechanism and tenderness to the mastoid area, CT head was obtained which was read as “small volume of fluid within the mastoid and middle ear cavity, intracranial gas interposed between the mastoid and sigmoid sinus, and within the R jugular foramen.” Neurologic exam remained normal with stable vital signs. He had no change in his symptoms. Due to these findings, he was transferred to CNMC ED for further evaluation.

En route, patient remained neurologically and hemodynamically stable. On arrival, he had a normal neurologic exam and was still complaining of mild right sided headache and tenderness to palpation to right mastoid area with an abrasion. States he has an “ear popping” sensation in his right ear. Unable to visualize due to cerumen impaction and didn’t tolerate cerumen removal. No other additional concerning findings on his exam.

Pediatric radiologists read his outside films:

“Pneumocephalus is evident within the right jugular foramen, with a small fracture fragment projecting in its posterior most aspect. Pneumocephalus also evident at the right petro clival junction, with a small bony fragment projecting posteriorly; from there, a fracture extends vertically into the posterior most carotid canal.  Small amount of air also evident within the carotid canal on the right.”

Discussed case with radiology who recommended CTA Brain to evaluate degree of carotid involvement. CTA Brain showed “Slight vessel wall irregularity of the petrocavernous segment of the right internal carotid artery. No evidence of dissection, transection or occlusion. This may suggest a Biffl grade 1 injury.” CT cervical spine was also obtained which was negative.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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