Delayed traumatic ocular emphysema: a case report

Subcutaneous Emphysema of the Orbit after Nose-Blowing

Orbital emphysema after nose-blowing is an uncommon condition and can appear without a trigger. Herein, we reported a case of orbital emphysema after nose-blowing and performed a literature review. A 68-year-old man fell and sustained an injury near his left orbit. No symptoms were noted. He noticed a left periorbital swelling after blowing his nose. Through computed tomography examination, he was diagnosed with subcutaneous emphysema. There are no previous reports that have reviewed the clinical features, need for surgery, and severity of symptoms of subcutaneous emphysema after nasal swallowing due to different factors. We retrospectively analyzed a cohort of 48 cases by searching PubMed to clarify these issues. Regarding the emphysema trigger, 21 cases had an injury or had previously undergone surgery. In 34 cases, conservative treatment was required, while surgery was selected in the acute phase in 6 cases and after the acute phase as a radical cure in 8 cases. Reduced visual acuity, diplopia, exophthalmos, facial hypoesthesia, and color disorders were noted and were more common among surgical cases. The literature review revealed no association between fracture location and the need for surgery; furthermore, surgery was less required in non-trauma cases, excluding osteoma, than in trauma cases (p = 0.0169). Our study reveals that a strict follow-up examination of visual symptoms is necessary for the first 2 days in cases of subcutaneous emphysema caused by nose blowing after facial trauma.

Isolated Medial Orbital Wall Fracture Associated with Enophthalmos in a Paediatric Patient: An Unusual Presentation

Purpose

To report a case of isolated medial orbital wall fracture with enophthalmos in a paediatric patient and describe the clinical presentation and findings by means of computed tomography (CT) of the head and eyes.

Methods

We looked at the patient's medical and ophthalmologic history, and an ophthalmologic examination and a CT of the head were performed at baseline.

Results

A 14-year-old boy was admitted to the emergency department of our institution with ecchymosis of his right eyelids secondary to a sport accident. Physical examination revealed a moderate limitation of upgaze without diplopia. CT showed a medial orbital wall fracture without haemorrhage and a gross accumulation of air in the right eyelid with pressure exertion over the right globe and enophthalmos. The patient was treated conservatively with oral antibiotics and steroids showing dramatic improvement within 1 week. Enophthalmos and periorbital emphysema were completely resolved within 3 months after the accident as indicated by CT.

Conclusions

We conclude that surgical intervention and intravenous treatment are not warranted in similar cases of medial orbital wall fracture. Medical history, clinical and paraclinical evaluations, and a regular follow-up, including CT, are needed though to avoid complications such as painful abduction, horizontal diplopia, pseudo sixth nerve paresis, or pseudo Duane.

Orbital Emphysema and Orbital Floor Fracture following a Severe and Prolonged Sneezing Attack

We present here a rare case of barotraumatic orbital blowout fracture. An 18-year-old man with sudden swelling of the right orbital region after severe and prolonged sneezing attack presented to our emergency department. Computed tomographic examination demonstrated a blowout fracture of the right orbital floor, which led to orbital emphysema and herniation of the orbital soft tissue. He was managed with nasal decongestants, steroids, anti-inflammatory drugs and an antibiotic. He developed no visual disturbance subsequently. (Hong Kong j.emerg.med. 2015;22:256-258)

Subcutaneous emphysema after vigorous sneezing in the setting of acute frontal sinusitis

INTRODUCTION

Subcutaneous emphysema [SCE] can develop due to traumatic, infectious, and spontaneous causes and usually localizes to the periorbital space.

CASE

We present a case of an 18-year-old male with an 8-day history of migraine-like headaches followed by the acute onset of frontofacial swelling after vigorous sneezing. Radiologic and physical exam findings supported a diagnosis of frontofacial SCE in the setting of frontal sinusitis.

DISCUSSION

A sneeze, although usually benign, causes a significant increase in intranasal pressure. When coupled with a history significant for facial trauma or rhinosinusitis, this rise in pressure can be sufficient to cause fracturing of the bone overlying a paranasal sinus, leading to the formation of SCE.

A peculiar blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: A case report and review of the literature

Background:

Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event.

Case Report:

A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired.

Conclusions:

Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.

Orbital emphysema after a protracted episode of sneezing in a patient with no history of trauma or sinus surgery

Orbital emphysema is a benign self-limiting condition. It can occur directly (as a result of trauma to the face) or indirectly (secondary to a blowout fracture). We report a case of orbital emphysema in a 38-year-old man who presented with ecchymosis of the right eye, pressure within the right orbit, and periorbital swelling following a protracted episode of vigorous sneezing. The diagnosis was confirmed by computed tomography. Systemic antibiotics were given, and the patient was cautioned to avoid blowing his nose. His signs and symptoms resolved within 1 week.

Orbital floor fracture and emphysema after nose blowing

INTRODUCTION

Orbital floor fractures are usually the result of mechanical trauma. Orbital emphysema tends to develop in fractures affecting the paranasal sinuses and walls of the orbit.

CLINICAL CASE

We report the case of a 35-year-old male who suffered an orbital floor fracture with associated orbital emphysema as a result of nose blowing.

DISCUSSION

Only one other similar case has been found in the literature.

Delayed appearance of diplopia due to orbital emphysema after repair of orbital fractures

A 38-year-old caucasian male, after continuous nose blowing caused by common flu, developed left diplopia, especially in downward gaze, and complained of orbital dull pain during the preceding 48 hours. Clinical signs included left lower eyelid crepitant edema, mild exophthalmos and restriction of the eye movement. The patient had been operated on for orbital fractures 12 days previously. Open reduction had been performed, stabilization had been achieved with osteosynthesis miniplates, and the orbital floor defect was reconstructed with a piece of Liodura. Orbital computerized tomographic scan demonstrated a large air collection, diagnostic of emphysema, without displacement of the fractures. Under local anesthesia, aspiration-decompression was performed using a 25-gauge needle. On the next day, the patient was free of pain, and 2 days after surgery the diplopia and exophthalmos resolved with no sequelae.