What is Battle Sign?
The Battle Sign, also known as Battle’s Sign, is essentially a bruise that appears behind the ear, on the bone called the mastoid process. This typically happens after a person has a head injury. The name Battle Sign comes from Dr. William Henry Battle, an English surgeon who first discovered it in the late 1800s. When treating 17 patients who had head injuries with fractures at the back of their skulls, he noticed this bruising. According to Dr. Battle, if someone has this sign, it means they have suffered a strong head injury which could potentially harm not just the back of the skull or the mastoid, but also the brain itself.
What Causes Battle Sign?
Battle sign, a symptom of head trauma, may take 1-2 days to appear, and this delay makes it not very useful in the initial treatment of head injuries.
The name “Battle sign” often causes confusion. Some people think it’s named so because it is related to injuries from fighting or battling, but it’s actually named after Dr. Battle. However, it should be noted that he wasn’t the first to spot it. An English surgeon, Sir Prescott G. Hewett, had written about it before Dr. Battle.
It may be difficult to distinguish between Battle sign and the spreading of blood under the skin from a less serious jawbone fracture.
Moreover, a recent report revealed that Battle sign occurred in a case of hepatic encephalopathy (brain disorder caused by liver damage) and not due to head trauma, suggesting that Battle sign might not always indicate head trauma. More research is still needed on its association with hepatic encephalopathy.
Risk Factors and Frequency for Battle Sign
Only a small percentage, 4%, of individuals with severe head injuries have basilar skull fractures. There isn’t a higher likelihood for them to occur in any gender or racial group. The Battle sign, which is often associated with blows to the head, normally happens due to accidents but can also be a result of non-accidental trauma, including child abuse.
The majority of skull fractures are linear, meaning they follow a straight line, and these are more likely to happen in children. Out of all skull fractures, 45% affect the temporal bone, with basilar skull fractures making up 20%. When a skull fracture is depressed, or pushed inwards, it generally requires immediate surgery as it’s typically an open fracture, meaning the skin above the fracture is broken or missing.
- Basilar skull fractures occur in only 4% of severe head injury cases.
- These fractures occur in all genders and racial groups without increased probability.
- Battle sign, a symptom correlating to head trauma, can happen due to accidents or non-accidental trauma such as child abuse.
- Most common skull fractures are linear and are more likely to occur in children.
- 45% of all skull fractures involve the temporal bone, while 20% are basilar skull fractures.
- A depressed skull fracture, when the bone is pushed in, is most often an open fracture requiring immediate surgical intervention.
Signs and Symptoms of Battle Sign
Battle sign is a term used to describe a particular type of bruising that can appear behind the ear over a bony area known as the mastoid process. This bruising is typically paired with sensitivity or pain in the same location. It’s a sign that is most commonly found in people who have suffered a basilar skull fracture, which is a type of break in the bone at the base of the skull. Additional signs that may point to a basilar skull fracture include:
- “Raccoon eyes”, which is bruising around both eyes
- Hemotympanum, or blood gathering in the middle ear
- Injury to the facial nerve
- Cuts or lacerations in the external auditory canal, or the passage leading to your eardrum
If a person shows the Battle sign, there’s a greater than 75% chance that a basilar skull fracture is present. In fact, studies have shown that seeing the Battle sign means a 66% chance there’s a brain lesion and a 100% chance of a skull base fracture.
Testing for Battle Sign
Battle sign is a symptom that doesn’t need any special tests to identify, but since it can signal a skull fracture, patients usually do need imaging tests for further examination. This is usually done with an uncomplicated CT scan. However, in some cases, fractures that are either straight line or carefully adjusted might not be visible and will require more imaging tests. If the sign is detected later on and there’s a risk of infection, a CT scan with contrast dye or an MRI might be needed.
Checking for a nose bleed is also crucial because it could indicate that cerebrospinal fluid, or CSF, is leaking. This can be confirmed by analyzing the levels of a protein called tau transferrin or glucose.
Treatment Options for Battle Sign
How a skull fracture is treated depends on the specifics of the injury. If someone has a simple or linear skull fracture, and they aren’t showing any loss of neurological function and have a Glasgow Coma Scale (GCS) score of 14 or higher, they can often go home after being observed in the emergency room for some time. However, it’s crucial that they can be reached for follow-up checks if they start experiencing symptoms. All children with linear skull fractures should stay in the hospital overnight, regardless of whether they have neurological symptoms or not.
For more severe, or depressed skull fractures, surgery is typically required. Generally, the rule is that if the broken piece of skull has sunk more than 5 mm below the level of the surrounding bone, it will need to be surgically lifted. Surgery might also be needed if a blood clot, severe infection, or air space (pneumocephalus) has developed under the broken piece of skull.
If the skull fracture has caused an open wound or the person’s treatment has been delayed, they should also get a tetanus shot and antibiotics that can fight a wide range of bacteria.
Basilar skull fractures are a result of trauma, which means they need a thorough trauma assessment. Usually, these patients need to stay in the hospital so their condition can be monitored, and further treatment depends on the specific details of the fracture.
What else can Battle Sign be?
The Battle sign, a mark suggesting a certain type of injury, may also occasionally appear in cases of a liver-related brain disorder known as hepatic encephalopathy.
What to expect with Battle Sign
The Battle sign, a sign indicating a certain head injury, will gradually fade and recover over time. This may take a few weeks for the bruised area to clear up. However, if the Battle sign is present, it could signify a slower recovery from the head injury than originally anticipated.
Possible Complications When Diagnosed with Battle Sign
When people show signs of a condition known as ‘Battle signs’, it’s really important to check if they also have an injury in their neck bones. Studies suggest that 15% of people with a certain type of skull fracture at the base of the skull might also have a neck injury.
Recovery from Battle Sign
After a surgical procedure, it’s important to keep a close eye on patients to check for complications like internal bleeding in the brain, blockage of a vein by a blood clot, or changes in their mental state. For patients who weren’t required to undergo surgery, a check-up should be scheduled within the first day or two to assess their consciousness level and mental condition.
It’s crucial that all surgical patients have a repeat CT scan about a month and a half to two months after the procedure. The purpose of this second scan is to check for any abscesses, which are collections of pus that can cause inflammation and swelling. A follow-up is also needed to monitor for potential seizures and any neurological problems.
Preventing Battle Sign
The patient should be instructed to keep an eye out for symptoms like CSF otorrhea (leakage of brain fluid through the ear) and fever. This knowledge can help in early identification of any complications.
