A 43-year-old man presents to the emergency department after falling down a flight of stairs and landing on his head. He did not lose consciousness. He complains of severe headache, marked decreased acuity in hearing in the left ear, and a “runny nose” since the fall. On physical examination, he is found to have a left sided Battle’s sign (an ecchymosis in the area of the left mastoid process) and hemotympanum. He has a constant dripping of a clear, watery fluid through his nose. Findings on his neurologic examination, other than the hearing loss, are completely normal. X-ray studies will reveal which of the following?
A 43-year-old man presents to the emergency department after falling down a flight of stairs and landing on his head. He did not lose consciousness. He complains of severe headache, marked decreased acuity in hearing in the left ear, and a “runny nose” since the fall. On physical examination, he is found to have a left sided Battle’s sign (an ecchymosis in the area of the left mastoid process) and hemotympanum. He has a constant dripping of a clear, watery fluid through his nose. Findings on his neurologic examination, other than the hearing loss, are completely normal. X-ray studies will reveal which of the following?
π‘ Explanation
**Core Concept**
The patient's presentation suggests a traumatic injury to the head, with specific findings indicating a fracture of the temporal bone. The temporal bone houses the structures responsible for hearing and balance, and a fracture in this area can lead to complications such as hemotympanum, conductive hearing loss, and cerebrospinal fluid (CSF) leak.
**Why the Correct Answer is Right**
The patient's symptoms, including hemotympanum, a clear, watery fluid dripping from the nose (indicative of CSF leak), and conductive hearing loss, are consistent with a temporal bone fracture. The presence of a Battle's sign, an ecchymosis in the area of the left mastoid process, further supports this diagnosis. A temporal bone fracture can occur due to the force of the fall, resulting in a fracture of the petrous part of the temporal bone.
**Why Each Wrong Option is Incorrect**
**Option A:** A frontal sinus fracture would not typically present with the specific combination of symptoms seen in this patient, including hemotympanum and CSF leak.
**Option B:** A mastoid process fracture, while possible, would not typically result in a CSF leak through the nose.
**Option C:** A petrous apex fracture is a rare injury that would not account for the patient's conductive hearing loss and hemotympanum.
**Clinical Pearl / High-Yield Fact**
Temporal bone fractures are often associated with significant head trauma, and a high index of suspicion should be maintained for these injuries in patients with head trauma and specific findings such as hemotympanum and CSF leak.
**Correct Answer:** C.
β Correct Answer: C. A temporal bone fracture with paradoxical rhinorrhea
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