Raccoon eyes are bilateral periorbital ecchymoses that occur without direct facial trauma. They often indicate a basilar skull fracture and result from bleeding into the periorbital tissues when the meninges or venous sinuses are torn. These ecchymoses may be the only visible sign of a basilar skull fracture, which may not be apparent on plain skull X-rays. Raccoon eyes may also develop post-craniotomy if the surgery causes meningeal tears.

Pathophysiology

• Basilar skull fractures can tear the dura mater and venous sinuses, allowing blood to track along fascial planes into periorbital tissues.

• Bleeding is typically slow and gravity-dependent, producing the characteristic bilateral dark periorbital discoloration.

• Associated cerebrospinal fluid (CSF) leakage may occur from the nose (rhinorrhea) or ear (otorrhea) if the dura is breached.

History and Physical Examination

History:

• Determine timing, mechanism, and severity of head injury.

• Ask about neurologic symptoms: headache, vomiting, vision or hearing changes, LOC changes.

• Inquire about recent cranial surgery if post-operative.

Physical Examination:

• Level of Consciousness (LOC): Assess using the Glasgow Coma Scale.

• Cranial Nerves (CN) Assessment: Focus on CN I (olfactory), III (oculomotor), IV (trochlear), VI (abducens), and VII (facial).

• Visual and Auditory Testing: Evaluate visual acuity and gross hearing if patient condition permits.

• Inspection:

  • Facial and skull irregularities, swelling, tenderness

  • Battle’s sign (mastoid ecchymosis)

  • Lacerations on scalp or face

  • CSF leakage from nose or ear

• CSF Detection:

  • Place sterile 4″ × 4″ gauze to collect drainage

  • Look for halo sign (clear fluid encircling blood)

  • Test fluid with glucose reagent strip—positive indicates CSF

Medical causes

Assessment and Diagnostic Workup

• Neurologic Monitoring: Frequent LOC assessment and cranial nerve testing

• Vital Signs Monitoring: Hourly checks for bradypnea, bradycardia, hypertension, fever

• Imaging:

  • Skull X-ray (may miss fracture)

  • CT scan for precise fracture location

  • Contrast cisternography if dural tear suspected

• CSF Testing: Glucose strip or lab analysis to confirm CSF in nasal/aural discharge

Management principles

• Bed Rest: Complete rest to prevent worsening dural tear

• Activity Restrictions: Avoid nose blowing, coughing, or straining

• Drainage Care: Place sterile gauze under nose/ear to collect CSF; do not attempt suction

• Infection Prevention: Monitor for meningitis signs (fever, nuchal rigidity); prophylactic antibiotics may be indicated

• Surgical Intervention: If dural tear does not heal spontaneously, consider surgical repair

• Pain Management: Analgesics as needed

• Frequent Neurologic Assessments: Monitor for deterioration

Patient counseling

• Educate about signs of neurologic deterioration: confusion, vomiting, worsening headache, vision changes

• Instruct on activity limitations to prevent worsening injury

• Guide scalp wound care and drainage monitoring

• Advise on infection prevention and warning signs of meningitis

Pediatric considerations

• In children, raccoon eyes are usually secondary to basilar skull fracture after falls

• Assess for associated head trauma and cranial nerve deficits

• Monitor CSF leakage and neurologic status closely

References

1. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

2. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 7th ed. Maryland Heights, MO: Mosby Elsevier; 2010.

3. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.