What is raccoon eyes? Raccoon eyes are not associated with any trauma because of soft tissue of the face injuries. Raccoon eyes are the peri orbital ecchymosis because of the fracture of the base of the skull. The fracture of the base of the skull will lead to tear in the meninges. This will cause the venous sinus to bleed into the cranial sinuses and arachnoid villi.Fracture of the base of the skull which is also known as basillar fracture of the skull is not always visible on the skull X rays. Here, raccoon eyes are the essential indicator of basilar fracture of the skull. The appearance of raccoon eye should alert the clinician for careful assessment of the brainstem, blood vessels and cranial nerves which may damage because of underlying trauma. Surgical procedure such as craniotomy may also cause raccoon eyes because of tear in the meningeal.
How to recognized raccoon eye? It is easy to differentiate between raccoon eyes and black eye. The black eye is associated with facial trauma. The raccoon eye will develop after a closed head injury such as basilar skull fracture. The black eye that occurs because of facial trauma may affect one or both eyes. Periorbital ecchymosis because of raccoon eyes will always effect both eyes bilaterally. The raccoon eye will develop 2-3 days after injury while black eye will develop hours after injury.
After the present of raccoon eyes are detected, the patient should be evaluated using the Glasgow Coma Scale to assess the level of consciousness. Next, assess the vital signs of the patient. It is important to consider the nature and when the head injury occurred as well as evaluating the extent of the trauma.
The function of cranial nerves are assessed such as first cranial nerve or olfactory nerves, third cranial nerve or oculomotor nerve, fourth cranial nerve, or trochlear nerve, sixth cranial nerve, or abducens nerve, and seventh cranial nerve, or facial nerve. Observed for any symptoms and signs of raised intracranial pressure. It is vital to test for the patient gross hearing and visual acuity. Swelling localized pain; irregularities of the skull or facial bones and facial or scalp laceration should be noted. Check and inspect for any leakage of CSF (cerebrospinal fluid) or hemorrhage from the ears and nose as well as ecchymoses over the mastoid.
The drainage is tested by using a glucose reagent stick to detect the present of glucose. The present of glucose indicates the present of CSF as mucous does not contain any glucose. The drainage also can be tested using gauge pad or sterile 4” x 4” . The present of circle of clear fluid which surrounds the drainage “ halo sign” indicates CSF.
The differential diagnoses of raccoon eyes are surgical and medical causes. The surgical cause is craniotomy. The raccoon eye will develop because of meningeal tear and bleeding into the sinuses after craniotomy.
The medical causes are the fracture of the base of the skull/ basilar skull fracture. Basilar skull fracture will produce the raccoon eye because of the trauma to the head which does not involve the orbital area. Associated symptoms and signs are drainage of blood or CSF, bulging of the tympanic membrane, epistaxis, ottorhea, rhinorrhea and pharyngeal hemorrhage. The patient may present with positive Battle’s sign, loss of consciousness, cranial nerve palsies, vomiting, nausea, headache and difficulty in hearing.
Patient is kept on complete bed rest. Always be alert. The vital sign is checked hourly. Frequent neurological evaluation is performed to assess the level of consciousness. Monitor the patient thoroughly and look for any changes such as fever, hypertension, bradycardia and bradypnea. Patient is advised not to strain, cough vigorously and not to blow the nose to avoid worsening of the dural tear. The patient is advised to use a loose sterile gauge pad and place it under the ear or nose in case of ottorhea or rhinorrhea to absorb the drainage. Glucose reagent strip will detect the present of CSF leakage. It is advisable not to pass a nasogastric tube or suction through the nose of the patient to prevent further infection and tearing of the mucous membrane. Prophylactic antibiotic is considered if the patient started to develop nuchal rigidity or fever (symptoms and sign of meningitis).
Cisternography is considered to find the location of the tear and might followed by corrective surgery. Investigations such as CT scan or skull X ray should be considered.
In children, raccoon eyes are mostly cause by fracture at the base of the skull because of fall. Patient should be instructed on how to look after the wound on the scalp and report to the clinician when the symptoms and signs of deterioration of neurological function are present.
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