ENT Signs in Basilar Skull Fracture | Battle Sign, Halo Sign, Laugier Sign & Raccoon Eyes Sign
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ENT Signs in Basilar Skull Fracture
Several classical signs are seen in basilar skull fractures. In this post, we will discuss:
- Battle Sign
- Halo Sign
- Laugier Sign
- Raccoon Eyes Sign
Battle Sign
📌 Type of Sign
👉 Clinical Sign seen during Examination of the ear.
🔍 What is the Sign?
Battle Sign refers to bruising or ecchymosis over the mastoid region behind the ear, appearing after head trauma.
Seen in Middle Cranial Fossa Fracture.
🧠 Why Does it Occur?
Blood from the skull base fracture tracks into the subcutaneous tissues behind the ear, producing a bluish black discoloration over the mastoid process.
⭐ Appears 6-24 hours after injury. It is never immediate.
👨⚕️ Eponym
Named after William Henry Battle, a British surgeon, who described mastoid bruising as a sign of basilar skull fracture.
💡 Mnemonic - The Four B's
| B | Meaning |
|---|---|
| B | Battle Sign |
| B | Bruise |
| B | Basilar skull fracture |
| B | Behind the ear |
👉 Battle Sign is a bruise in basilar skull fracture, behind the ear.
What is the most common artery involved in middle cranial fossa fracture?
What is the artery involved in Battle sign?
Halo Sign
📌 Type of Sign
👉 Clinical Sign
A bedside test performed in suspected CSF leak (CSF otorrhea or CSF rhinorrhea).
What are the other names of Halo sign seen in CSF leaks?
🔍 What is the Sign?
Halo Sign refers to a double ring appearance produced when discharge mixed with CSF is dropped onto a filter paper.
🩺 How is it Performed?
The nasal discharge, often seen trickling when the patient bends forward, is allowed to drop onto a piece of filter paper.
A positive sign is:
✅ A central dark blood spot with an outer clear ring of CSF
🧠 Why Does it Occur?
CSF has a lower viscosity than blood, so it diffuses further on the filter paper.
- CSF forms the outer lighter ring
- Blood concentrates in the centre as a dark spot
What is the most common cause of CSF leak?
⚠️ Important Points
❌ Halo Sign does not confirm CSF - it is only suggestive.
What is the Gold standard test to confirm CSF?
What is the most common and deadly complication of an untreated CSF leak?
⚠️ Important MCQ Trap
Do not confuse the two Halo Signs:
| Halo Sign | Type | Seen In |
|---|---|---|
| Halo Sign on filter paper | Clinical | Suspected CSF leak |
| Halo Sign on CT Temporal bone | Radiological | Cochlear otosclerosis |
Laugier Sign
📌 Type of Sign
👉 Clinical Sign seen during Otoscopy.
🔍 What is the Sign?
Laugier Sign refers to the presence of blood behind the tympanic membrane (hemotympanum) following trauma.
Seen in Basilar skull fracture, particularly temporal bone fractures.
Decribe the otoscopic findings of Laugier sign.
🧠 Why Does it Occur?
Basilar skull fracture
→ Tear of the vessels in the temporal bone
→ Leaking of blood into the middle ear cleft
→ Discoloration of the tympanic membrane
👨⚕️ Eponym
Named after Laugier, who described hemotympanum as a diagnostic clue in basilar skull fractures.
⚠️ Important Viva Point
Hemotympanum is called Laugier Sign only when it follows trauma.
What are other Causes of Hemotympanum?
Raccoon Eyes Sign
📌 Type of Sign
👉 Clinical Sign seen during Examination of the eyes.
📌 Also Known As
👉 Panda Eyes Sign
🔍 What is the Sign?
Raccoon Eyes Sign refers to bilateral periorbital bruising or ecchymosis, giving a dark discoloration around the eyes.
Seen in Anterior Cranial Fossa Fracture.
🧠 Why Does it Occur?
Blood tracks into the loose periorbital tissues around the eyes.
🐼 Why is it Called Raccoon Eyes Sign?
The dark discoloration around the eyes resembles the eyes of a raccoon or a panda, hence the names Raccoon Eyes Sign and Panda Eyes Sign.
⚠️ Important Viva Point
| Sign | Site of Fracture |
|---|---|
| Raccoon Eyes Sign | Anterior cranial fossa |
| Battle Sign | Middle cranial fossa |
⭐ High Yield Rapid Revision Table
| Sign | Elicited By | Finding | Indicates |
|---|---|---|---|
| Battle Sign | Examination of the ear | Bruising over the mastoid, 6-24 hours after injury | Middle cranial fossa fracture |
| Halo Sign | Discharge dropped on filter paper | Central dark blood spot with an outer clear ring | CSF leak (otorrhea / rhinorrhea) |
| Laugier Sign | Otoscopy | Hemotympanum following trauma | Basilar skull fracture, especially temporal bone |
| Raccoon Eyes Sign | Examination of the eyes | Bilateral periorbital ecchymosis | Anterior cranial fossa fracture |
🧠 Viva Pearls
- Battle Sign is bruising over the mastoid region behind the ear.
- Battle Sign appears 6-24 hours after injury and is never immediate.
- Battle Sign indicates a middle cranial fossa fracture.
- Halo Sign occurs because CSF has a lower viscosity and diffuses further than blood.
- Halo Sign is only suggestive of CSF, not confirmatory.
- A radiological halo sign is seen in cochlear otosclerosis, and should not be confused with the filter paper halo sign.
- Laugier Sign is hemotympanum following trauma.
- Raccoon Eyes Sign is also known as panda eyes sign.
- Raccoon Eyes Sign indicates an anterior cranial fossa fracture.
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