Raccoon Eyes (Periorbital Ecchymosis)

Raccoon eyes is most often caused by a basal skull fracture (BSF). The basal part of your skull is the bottom portion where the brain rests. When a fracture occurs, symptoms such as raccoon eyes may follow. BSF can occur from car accidents, falls, sports injuries, and other sources of head trauma.

Another possible cause of raccoon eyes is the breaking of the thin bones that surround your eyes. This can result from facial injuries. A broken nose or broken cheekbones are other possible causes.

It’s important to note that raccoon eyes may not develop immediately after an injury. If head or facial swelling remains within a couple of days, then raccoon eyes may soon follow.

Differential diagnosis

A differential diagnosis is when doctors have to rule out conditions that have very similar symptoms. Although trauma is the most common cause of raccoon eyes, other conditions can also cause it, such as:

• amyloidosis
• Kaposi’s sarcoma
• multiple myeloma
• neuroblastoma

More rarely, allergies can also cause raccoon eyes, but the coloring is typically less prominent.

Symptoms of raccoon eyes include bruises, primarily visible around the eyes. These bruises and the surrounding areas don’t tend to be painful or tender, unless they’re caused by facial fractures. The bruises can range in color from red to purple, or from blue to black. They’re often so large that they extend beyond the eyes to the temples, cheeks, and forehead.

Other physical symptoms of raccoon eyes and related skull fracture include bruises behind the ears, called “battle’s sign.”

Other, less visible symptoms can also occur. You may have:

• blood behind your ear drums
• hearing loss
• high blood pressure
• nosebleeds
• vision changes or double vision
• weakened sense of smell
• weakness in your face from resulting nerve damage

Your doctor will diagnose raccoon eyes as a sub-condition of BSF. They’ll perform a physical exam and may take note of the bruises around your eyes. However, imaging tests are considered more critical because they can show your doctor pictures of internal damage.

To diagnose raccoon eyes, your doctor will likely use a CT scan. CT scans successfully find brain and skull injuries in two out of three people. X-rays can’t detect the sources of raccoon eyes as effectively.

Sometimes this condition isn’t diagnosed until a person arrives at the hospital from a related head injury.

Left untreated, raccoon eyes and associated BSF can lead to further complications. In addition, any head injury severe enough to cause BSF can also cause significant brain injury related to the trauma. Your doctor will need to monitor your condition for the development of:

• aneurysms
• blood in your eyes
• cerebrospinal fluid leaks
• deformities of the skull or face
• meningitis
• post-traumatic facial palsy
• related fistulas — abnormal connections between arteries, organs, and veins
• bleeding in or around the brain
• post-concussive syndrome

BSF, the most common cause of raccoon eyes, frequently doesn’t need treatment. In fact, most fractures of this nature heal by themselves without intervention.

Instead, your doctor may treat other complications if they arise. Cosmetic surgery may be an option if you’re concerned about any deformities. Cerebrospinal fluid leaks may also require surgery to stop them. Other complications, such as meningitis or an aneurysm, require careful monitoring and follow-up to make sure these conditions don’t get worse.

Raccoon eyes tend to go away once your skull fracture heals. Overall, the outlook for this condition also depends on any complications that arise.

Some skull fractures may be fatal. It’s important to see your doctor right away if you’ve had a head injury and have the signs and symptoms of raccoon eyes. To be safe, any head injury should be checked out by your doctor as soon as possible.