John E. Monaco, M.D.
I am continually amazed by the capacity of the human body - particularly the teenage human body - to withstand injury. I was reminded of this fact the other day when I received a call from the ER telling me that they were caring for a 16-year-old young man who was in need of admission to the hospital for close observation. It seems that he had fallen from a 12-foot high scaffold, landing on his back and head. He had not lost consciousness, but there was concern because bloody fluid was leaking out of his left ear. His name was Jason, he was otherwise completely healthy and he had already been evaluated by the neurosurgeon who felt he was stable for admission from the ER. In other words, he did not require surgery or other emergency interventions.
In discussing the case with the emergency physician, I learned that Jason had been standing on a concrete block that was on a scaffold plank when the block became unstable. He then apparently lost his balance and fell backward, the cement block following him as the scaffolding plank became dislodged. When he hit the ground, the block fell on top of him and hit him on the side of the head. All in all it was a frightening injury, and I was amazed that Jason had not lost consciousness and he had not, as yet, demonstrated signs of concussion (concussion is defined as any alteration in consciousness following a head injury and is caused by rapid acceleration and deceleration of the brain within the skull causing sheering of tiny blood vessels and temporary injury to brain cells). The focus of concern for this boy was the fluid leaking from his ear. Why was this significant?
Skull fractures are an interesting and quite common phenomenon in children. Interestingly, rarely do they require surgical "repair" as such. Only when the fracture is depressed into the brain, or if blood vessels are torn as a result of the fracture, is surgical repair necessary.
Jason's injury was important because leakage of fluid from the nose or ear raises the possibility of a "basilar" skull fracture. As the name suggests, this is a fracture that is most often linear, and extends into the base of the skull, which makes it quite difficult to discern on CT scan or plain x-ray. Other signs of a basilar skull fracture include bruising behind the ears or blood visible behind the eardrum. Because the coverings of the brain are very close to the surface of the base of the skull, fractures in this region can result in tears in these coverings, which may result in leakage of spinal fluid. When spinal fluid leaks out, its most common sites of emergence are the ears and nose. So, the concern was that the fluid from Jason's ear was spinal fluid indicating a basilar skull fracture, thus risking exposure of the brain to infection and further injury.
A repeat CT scan looking more specifically at the base of the brain did not reveal a fracture but sometimes these linear fractures can be very subtle and difficult to discern even on sophisticated scans. Jason would have to be watched until the leakage subsided, in case any other symptoms of head injury were to evolve. Detecting fractures is important because their presence gives some indication of the actual force of the head injury. In other words, if there is enough force exerted to crack a very strong skull bone, then there is reason to worry about the degree of shock the underlying brain might have sustained. Even though Jason had not yet exhibited signs of significant head injury, such symmptoms could still evolve, and he would have to be watched closely.
The plan was to admit Jason to our Pediatric ICU, place him on monitors, and perform vital signs and "neuro" checks every hour. "Neuro" checks involve asking the patient questions to assess his degree of orientation, as well as performing a modified physican examination. We planned also to have the ENT doctor evaluate him to see if the bleeding was due to a tear in the coverings of the brain or simply trauma to the ear canal itself. Initially, we were a bit worried because we had a difficult time arousing Jason, even to get him to answer questions. Even though this was several hours after his fall, a change in neurological status, such as difficulty arousing the patient, can be an early sign of brain swelling, or late bleeding into the brain.
After eight hours in the unit, however, long enough for Jason to catch up on the sleep he missed from spending the night in the ER, he was completely alert, awake and talking back to us like any normal 16-year-old boy. The ENT doc determined that he had only suffered minor ear trauma, and she felt the brain coverings were intact, especially since no fracture was seen on any of the studies. Finally, the nurse informed me that she thought Jason had completely returned to his normal state of well being. When I asked her how she knew this, she stated that she was pretty sure after she caught him trying to light up a cigarette in his ICU room. Ah, the resilience of the young, I thought to myself, and then wondered, as the parent of two teens, how it is that any of these kids survive their teenage years!
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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