Posttraumatic orbital emphysema: incidence, topographic classification and possible pathophysiologic mechanisms. A retrospective study of 137 patients

Successful treatment of a rare subcutaneous emphysema after a blow-out fracture surgery using needle aspiration: A case report

BACKGROUND

Many cases of emphysema associated with blow-out fractures occur before surgery due to trauma. However, emphysema can occur even after surgery, and most of such cases are managed conservatively and allowed to resolve. Swelling in the periorbital area due to emphysema that occurs after surgery can make early recovery difficult.

CASE SUMMARY

Herein, we describe a case of postoperative subcutaneous emphysema that was treated using a simple needle aspiration method. A 48-year-old male patient visited the hospital with a blow-out fracture of the left medial orbital wall and nasal bone fracture. One day postoperatively, swelling and crepitus in the left periorbital area were observed, and follow-up computed tomography showed emphysema in the left periorbital subcutaneous area. Needle aspiration using an 18-gauge needle and syringe was used to relieve the emphysema. The symptoms of sudden swelling improved immediately, and no recurrence was observed.

CONCLUSION

We conclude that needle aspiration is a useful method that could help in relieving symptom, resolving discomfort, and enabling early return to daily life in patients with postoperative subcutaneous emphysema.

Orbital emphysema as a result of chest tube placement for recurrent pneumothorax

Orbital emphysema refers to the presence of air or gas within the orbital soft tissue space. Although orbital fracture due to trauma is the most common cause, iatrogenic orbital emphysema from chest tube insertion is a rare but potentially serious complication from the treatment of pneumothorax. Symptoms can range from mild crepitus of the periorbital region to permanent vision loss secondary to central retinal artery occlusion or optic neuropathy, a result of orbital compartment syndrome. Management is dependent on the presence of orbital signs and vision loss. Herein, we present a rare case of orbital emphysema in the setting of pneumothorax and chest tube insertion in a 62 year-old patient admitted to the hospital floor. Presenting symptoms included vision loss and bilateral orbital edema, while physical exam revealed complete ptosis of the right eye with diffuse periorbital emphysema and crepitus. Diagnosis was confirmed clinically and with CT head and orbits. The patient's vision loss was felt to be secondary to ptosis; thus, interventions were not necessary and his condition resolved with observation. The present case and associated literature review highlights orbital emphysema as a complication of chest tube insertion and pneumothorax, as well as the drastic complications of the condition if left untreated.

Orbital and Intracranial Emphysema Causing Orbital Compartment Syndrome: A Rare Case Report and Literature Review

A case of 50-year-old male who presented with orbital compartment syndrome as a sequela of mid facial trauma, and literature review. Orbital compartment syndrome (OCS) is one of the potentially sight threatening emergencies encountered in clinical practice. Acute rise in pressure within the confined orbital cavity compromises the blood flow to retina and optic nerve leading to irreparable vision loss. Air entrapped in the orbital cavity leading to orbital compartment syndrome has been rarely reported. A brief literature search for the term orbital emphysema in PubMed yielded 352 articles out of which 280 articles were identified after screening for appropriate titles and case reports. A total of 138 patients were reported in the literature with severe orbital emphysema. Acute orbital compartment syndrome needs to be recognized and addressed on an emergency basis to achieve decompression so as to prevent an irreversible vison loss. Watchful eyes, an accurate diagnosis and timely surgical intervention could potentially reverse permanent damage to the optic nerve.

Traumatic Optic Neuropathy Aggravated by Orbital Emphysema after Orbital Fracture

Purpose: To report a case of traumatic optic neuropathy aggravated by orbital emphysema after an orbital fracture.Case summary: A 19-year-old man with no specific medical history was referred for a right orbital fracture caused by blunt trauma to the supraorbital rim of the right eye. Computed tomography (CT) showed a right orbital fracture involving the inferomedial wall and inferomedial strut. The corrected visual acuity was 0.4 in the right eye (RE) and 1.0 in the left and the intraocular pressure was 15 and 18 mmHg, respectively. Restriction on downgaze, abduction, and an indefinite relative afferent pupillary defect (RAPD) were observed in the RE. Fundus exam was non-specific other than commotio retinae on the temporal side of the macula in the RE. After 12 hours post trauma, the visual acuity of the RE had decreased to light perception. Definite RAPD was observed with optic disc swelling on the fundus photo and optical coherence tomography. Orbital CT showed air shadows, which were not seen on the initial evaluation, adjacent to the optic disc. We diagnosed traumatic optic neuropathy aggravated by orbital emphysema. High-dose intravenous steroid was given for 3 days. Despite a lateral canthotomy and cantholysis to decompress the right orbit, visual acuity did not improve above counting fingers.Conclusions: Increased intraorbital pressure and congestion caused by orbital emphysema may exacerbate traumatic optic neuropathy. Therefore, close observation is required.

Late Subconjunctival Emphysema in an Unrepaired Orbital Floor Fracture

A 42-year-old gentleman with a history of a left orbital floor fracture four years prior presented to the emergency department following a motor vehicle collision. He was without subjective eye concerns, although a physical examination revealed a superior temporal subconjunctival mass with crepitus of the left eye. Visual acuity was 20/20 bilaterally, pupils were reactive without a relative afferent pupillary defect, and extraocular movement was fully intact. A computed tomography scan of the face revealed left-sided subconjunctival, subcutaneous, and orbital emphysema determined to be associated with a previous orbital floor fracture. With no other medical concerns requiring immediate treatment, the patient was offered outpatient repair of the old orbital floor fracture.

Pneumomediastinum as a Complication of Oral and Maxillofacial Injuries: Report of 3 Cases and a 50-Year Systematic Review of Case Reports

Objectives

Pneumomediastinum (PM) secondary to oromaxillofacial trauma (OMF) is a rare but well-described complication/pathologic finding. The aim of this study was twofold: first, to report our experience in treatment of maxillofacial trauma patients with PM, and second, to review the literature regarding the clinical features, severity, course, and management of the aforementioned complication.

Material and methods

We retrospectively reviewed the medical records and charts of patients who suffered from maxillofacial trauma and treated in our hospital between September 1, 2013 and September 31, 2017. The inclusion criteria were patients with radiologically confirmed PM. In addition, the electronic databases PubMed, Scopus, and Science Direct were queried for articles reporting PM cases secondary to OMF injuries and published in English, French, and German language.

Results

Three cases of PM out of 3,514 cases of craniomaxillofacial trauma were found; there were 3 male patients who presented in our emergency department with the chief complaint of cervicofacial swelling. Literature search isolated 58 selected articles and 63 cases were assessed in total; posttraumatic repeated blowing of nose was proved as most frequent triggering factor among them. Furthermore, the outcomes of review showed that thoracic pain, respiratory distress, and swallowing difficulties were not frequently reported in patients with ME due to facial trauma.

Conclusions

Both our experience and the results of systematic literature review indicated that patients with PM due to OMF injuries present mild clinical course. If properly managed, this specific pathologic condition may have no further complications or relative comorbidities. The exact etiology and mechanism of PM in the context of maxillofacial injuries always needs to be identified. Radiographic, laboratory, and endoscopic examinations should be applied to rule out the more serious and frequently diagnosed aerodigestive, thoracic, and abdominal causes of PM.

Case Report: Atraumatic Orbital Emphysema after Bronchoscopy with Endobronchial Biopsy

SIGNIFICANCE

Orbital emphysema is a well-documented condition where air enters the orbital soft tissue typically because of direct or indirect trauma; however, atraumatic cases can be encountered. The following is a novel case report of acute unilateral atraumatic orbital emphysema 24 hours after bronchoscopy with endobronchial biopsy.

PURPOSE

To the best of the authors' knowledge, this is the first known case report of atraumatic orbital emphysema as a postprocedure complication of bronchoscopy with endobronchial biopsy in the literature.

CASE REPORT

A 74-year-old man presented with painless swelling of the left upper and lower eyelids upon awakening. The patient had a history of bronchoscopy and endobronchial biopsy with conscious sedation for a right upper lobe lung mass 24 hours before the visit. Slit-lamp examination revealed air entrapment in the left upper and lower lids with enlarged subconjunctival air pockets of the left eye. Head and maxillofacial computed tomography without contrast revealed extensive emphysema tracking and dissecting along the subcutaneous and deep soft tissue spaces of the neck and face that was more pronounced along the left side. The patient was admitted for overnight observation and prescribed a prophylactic oral course of 250 mg of azithromycin daily for 2 days by the attending hospitalist. The subsequent follow-up visit 3 days later revealed complete resolution of signs and symptoms.

CONCLUSIONS

This case report demonstrates the importance of considering orbital emphysema in patients with a history of recent bronchoscopy with endobronchial biopsy. Clinicians should be aware of this potential complication and refer for appropriate testing and comanagement.

Orbital Emphysema: A Case Report and Comprehensive Review of the Literature

PURPOSE

The objective of this study was to report a case of persistent and likely self-induced orbital emphysema (OE) following functional endoscopic sinus surgery with dislodgement of a previously placed orbital floor implant and to review the literature surrounding etiologies, pathophysiology, and management of OE.

METHODS

Case report and review of the literature.

RESULTS AND DISCUSSION

While blunt trauma resulting in disruption of the medial orbital wall is the most common cause of OE, there are an additional 25 underlying etiologies reported in the current literature. Pathophysiology of OE is somewhat dependent on underlying etiology but often involves a 1-way ball valve mechanism such that air may enter the orbit but not exit. When sufficient air enters the orbit, complications secondary to increased intraorbital pressure, including central retinal artery occlusion and compressive optic neuropathy, can occur. Mild cases of OE are typically observed, with most resolving within 7 to 10 days. Moderate cases are often managed by lateral canthotomy and cantholysis with possible needle decompression. Severe cases may require urgent surgical decompression. While the majority of cases of OE are benign and self-limited, there have been 4 reports in the literature documenting significant vision loss.

CONCLUSIONS

Although there is often a history of trauma in patients presenting with OE, many other underlying etiologies have been reported with several cases occurring spontaneously. As such, OE should be included on the differential for a patient presenting with a sudden onset of orbital signs.

[Acute compression of the optic nerve due to orbital emphysema]

Bony defects of the orbit with connection to the paranasal sinuses can lead to orbital emphysema. A case of compression of the optic nerve due to orbital emphysema in a 39-year-old man is reported. Visual acuity was hand movements only and intraocular pressure was increased to 32 mm Hg with an exophthalmus of 6 mm in comparison to the unaffected side. A sufficient pressure relief could be achieved by canthotomy with cantholysis and radial peritomy.

Retrobulbar Orbital Emphysema Associated With Medial Orbital Wall Fracture

Retrobulbar emphysema is a rare condition compared to the more common orbital emphysema. It is often associated with medial orbital wall fracture with rupture of the periosteum. In some severe patients, retrobulbar emphysema can increase the intraorbital pressure and lead to orbital compartment syndrome. Less extreme patients require only conservative treatment with careful observation. There is still no standard protocol for the management of orbital emphysema in general or specifically for retrobulbar emphysema. Visual acuity is the most widely used indicator to determine whether surgical intervention is needed. The patient presented here suffered from large retrobulbar intraconal emphysema and exophthalmos without visual loss after head trauma and nose blowing. He was observed closely without surgical intervention. After the emphysema had resolved, the patient's medial orbital wall defect was reconstructed using unsintered hydroxyapatite particles/poly L-lactide via the transcaruncular approach. The postoperative course has been uneventful with more than 1 year of follow-up to date.

Periorbital Emphysema After Endoscopic Nasal Polyp Surgery

Periorbital and subcutaneous emphysema after transnasal endoscopic surgery are rare. Periorbital emphysema has been reported after facial trauma, dental interventions, procedures such as endoscopic sinus surgery and rhinoplasty, and due to medications such as systemic steroids. Although very rare, it may require urgent intervention because of the risk of increased intraocular pressure and impaired blood supply to the globe. The otolaryngology department requested ophthalmology consultation for a 65-year-old male patient who had severe periorbital emphysema of the right eye the day after endoscopic nasal polypectomy due to severe coughing and straining. Crepitus was detected on skin palpation and immediate intervention was performed by passing a 21-gauge needle through the skin into the subcutaneous tissue of the upper and lower eyelids to evacuate the subcutaneous air. The patient’s clinical symptoms resolved with no postoperative complications.

Morphological characteristics and clinical manifestations of orbital emphysema caused by isolated medial orbital wall fractures

PURPOSE

To investigate the morphological characteristics and clinical manifestations of orbital emphysema in patients with isolated medial orbital wall fractures.

METHODS

This was a retrospective observational case series of 348 orbits of 348 patients with isolated medial orbital wall fractures. Medical charts were reviewed, and computed tomographic (CT) images were examined to determine the morphological characteristics of orbital emphysema.

RESULTS

Orbital emphysema was detected in 70 orbits (20.1%). Large and communited type fracture was related with the presence of orbital emphysema (P<0.05). Orbital air pockets were detected in medial or superior extraconal orbital segment in all cases with orbital emphysema. Swollen eyelid with crepitus (90.0%) and supraduction limitation (31.4%) were developed with orbital emphysema. All cases with supraduction limitation accompanied with superior extraconal orbital emphysema and superior rectus muscle deviation, and these eyes were fully recovered with conservative management without surgery.

CONCLUSIONS

Orbital emphysema can be a cause of ocular motility restriction following orbital wall fracture. If supraduction limitation is noted with isolated medial wall fracture and superior orbital emphysema with superior rectus muscle deviation is detected by CT scan, conservative management can be a good choice for spontaneous recovery delaying the surgery.

Orbital apex disorders: a case series

Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.