Orbital emphysema during air travel: a case report

CHORIORETINITIS SCLOPETARIA AND ORBITAL EMPHYSEMA CAUSED BY A HIGH-VELOCITY LIQUID MISSILE

PURPOSE

To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer.

METHODS

This is a retrospective case report.

RESULTS

A 19-year-old man presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus examination showed inferior vitreous hemorrhage, retinal whitening, and preretinal, intraretinal, and subretinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and postseptal orbital emphysema. Two months after injury, vitreous and retinal hemorrhages and macular hole resolved. Five months after injury, visual acuity improved to 20/20.

CONCLUSION

Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. Although this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

Orbital Fractures and Air Travel

Previous surveys indicate that the majority of clinicians recommend avoidance of air travel for a period of time following an acute orbital fracture. This advice has largely been based on the theoretical risk that in-flight pressure variation may exacerbate orbital emphysema and produce visual compromise, though no previous reviews have been conducted on the evidence underpinning this advice. The purpose of this study was, therefore, to conduct a systematic review of the literature pertaining to the safety of air travel in the setting of an acute orbital fracture. A systematic review of the OVID Medline database - and of cases referenced as providing evidence for adverse outcomes due to flying with an orbital fracture - was carried out.Two articles were identified from the literature with data specific to patients who undertook air travel following orbital fractures. A large case series identified no complications in patients exposed to both pressurized and unpressurized air travel, and only a single case report detailed an adverse outcome requiring intervention. The remainder of the articles that had previously been cited as evidence against air travel involved additional factors such as intra-ocular pathologies. There is, therefore, a paucity of evidence to support the conventional advice regarding avoidance of air travel, though clinicians should exclude the possibility of an associated intra-ocular injury, advise against nose-blowing in flight, and provide advice regarding alternative methods to the Valsalva maneuver for equalizing middle ear pressure in flight.

LEVEL OF EVIDENCE

IV.

Recurrent Self-Induced Nontraumatic Orbital Emphysema Causing Orbital Compartment Syndrome with Optic Nerve Dysfunction

The majority of cases of orbital emphysema are due to trauma. Complications are rare, and therefore, the need for surgical intervention is uncommon. We present the first case of which we are aware in which nontraumatic orbital emphysema led to orbital compartment syndrome and subsequent optic nerve dysfunction. The patient underwent emergency needle decompression. A 51-year-old man presented to the Emergency Department with right-sided unilateral proptosis, reduced visual acuity, and binocular diplopia. This occurred after performing a Valsalva manoeuvre with no history of head trauma. He also mentioned that over the past year he had experienced multiple episodes of transient proptosis occurring after Valsalva manoeuvres. Visual acuity in the right eye was reduced to 6/21. A relative afferent pupillary defect was present and intraocular pressure (IOP) was 12 mmHg. The CT scan showed significant orbital emphysema in the medial aspect of the right orbit. Needle decompression was performed resulting in immediate resolution of his symptoms. This case demonstrates that, in cases of orbital emphysema, a lack of a history of trauma and a normal IOP cannot always be used to rule out serious pathology.

Water balloon-induced orbital fracture in an aviator

BACKGROUND

Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature.

CASE PRESENTATION

A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status.

CONCLUSIONS

Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Orbital Emphysema: A Rare Postoperative Complication

Orbital emphysema can be a rare and severe postoperative complication. Fast and critical diagnosis is essential to avoid permanent visual loss to the patient. Therefore, a case of a male patient victim of a motorcycle accident with a postoperative complication of orbital emphysema has been presented. The immediate diagnosis and treatment of the orbital emphysema revealed to be the main success factors for the resolution of this complication.

Orbital, Periorbital, and Intracranial Emphysema Caused by Compressed Air Injury in a 5-Year-Old Child

A 5-year-old boy was accidentally injured by a compressed air blast to his right eye and developed periorbital and subconjunctival emphysema and proptosis subsequently. CT scan showed periorbital subcutaneous and intraorbital emphysema around the right eye, as well as intracranial and cervical emphysema without frank fractures in orbital bones. He was examined under sedation, and the subconjunctival air was aspirated. He was also prophylactically treated with topical and systemic antibiotics to prevent infection. Emphysema was resorbed entirely within 3 weeks. In conclusion, compressed air injury can occur in a child and manifest with orbital and periorbital emphysema without any detectable fracture and any clear entrance site and may need emergent management to save the vision or upper respiratory airways.

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.

[Pediatric orbital emphysema caused by a compressed-air pistol shot: a case report]

CASE REPORT

We report the case of a 2 year-old child with orbital emphysema secondary to a compressed-air gun shot in the malar region, with no evidence of orbital wall fracture. Conservative treatment was applied, and no complications were observed.

DISCUSSION

Orbital emphysema in the absence of an orbital wall fracture is a rare situation. Orbital emphysema is usually seen in facial trauma associated with damage to the adjacent paranasal sinuses or facial bones. To our knowledge there have been very few reports of orbital emphysema caused by a compressed-air injury.

Flying and midface fractures: the truth is out there

There are no clear, evidence-based guidelines that dictate when it is safe for a patient to fly after sustaining a midface fracture. From January 2006 to December 2009, the Royal Darwin Hospital Maxillofacial Unit had 48 out of 201 patients with an orbital fracture that involved a paranasal air sinus transported by a variety of aircraft to the unit for definitive management. No orbital complications were recorded for the 24% of patients requiring air travel to our tertiary referral centre. Furthermore, there were no recorded deviations from the standard flight plan. We believe that this demonstrates there are no absolute contraindications to flying on a variety of aircraft with a midface fracture, but clinical assessment remains crucial for an informed decision to transport these patients by air.

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.

Subcutaneous emphysema

Subcutaneous emphysema is a potential surgical complication arising due to introduction of air into the facial planes of the connective tissue. presence of air and accompanying inflammation and or infection could prove fatal in immediate post surgical scenario. This case report aims to prevent one such case of subcutaneous emphysema that was promptly diagnosis and effectively managed.

Orbital emphysema - the need for surgical intervention

INTRODUCTION

Orbital emphysema is a recognised complication of fractures of the orbit and only rarely poses a threat to vision.

PATIENTS AND METHODS

We present three patients with threatened vision secondary to orbital emphysema that required an immediate surgical decompression.

RESULTS

Visual function was preserved in all three patients.

CONCLUSION

Clinical awareness of pneumo-orbitism is vital as immediate orbital decompression may be necessary to preserve visual function.

Tension pneumo-orbit treated by endoscopic, endonasal decompression: case report and literature review

OBJECTIVE

We present a 38-year-old man with a tension pneumo-orbit following medial orbital wall fracture, managed with endoscopic decompression.

METHOD

A case report and a review of the world literature concerning the aetiology, clinical features and management of medial orbital wall fractures are presented.

RESULTS

Our patient presented with a post-traumatic tension pneumo-orbit exacerbated by air travel and nose-blowing. Computed tomography revealed a fracture of the ethmoid bone, and intra-orbital emphysema causing proptosis. Management with endoscopic, endonasal surgery produced excellent results, with decompression achieved and immediate and sustained improvement in visual acuity.

CONCLUSION

A search of the world literature revealed no documented cases of tension pneumo-orbit as a complication of medial orbital wall fracture. Endoscopic sinus surgery is currently used in the management of nasal and sinus diseases and their orbital complications. We discuss this extended indication of endoscopic surgery, and its advantages over other surgical approaches.

Delayed traumatic ocular emphysema: a case report

A 47-year-old man sustained fractures of the left orbita and zygomatic bone after a fall. He was advised to visit an oral and maxillofacial department for more detailed evaluation and treatment, but ignored the advice. Four days later, after sneezing and blowing his nose, he presented severe exophthalmos, diplopia, and reduction of vision. Two days after the symptoms presented he asked for oral and maxillofacial surgery consultation. He refused any surgical intervention and was treated conservatively. The recovery was slow and 1 week later he was discharged with slight esthetic problems.

Air travel and seizure frequency for individuals with epilepsy

This study investigated whether air travel is associated with an increase in seizures for individuals with epilepsy. Thirty-seven participants monitored their seizure frequency for one week prior to flying and for one week after flying. For the sample as a whole, seizures were significantly more common after flying (p=.02). No seizures were reported as occurring during flight. Participants who experienced an increase in seizures after flying compared to those who did not (a) had a higher baseline of seizure frequency (p=.004), (b) were more likely to have previously experienced an increase in seizures after flying (p=.001), (c) were more worried about having a seizure while flying (p=.001) and (d) were more likely to avoid air travel (p=.02). Participants with complete seizure control prior to flying did not experience seizures after flying. Distance traveled, time zones crossed, duration of flight and direction of flight were not significantly different for those with seizure increase than for those without such an increase. This study suggests that air travel promotes an increase in seizures for those with a prior history of flight related seizures and a relatively high baseline seizure frequency.

Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study

PURPOSE

The purpose of this report was to review and analyze the epidemiologic features of traumatic subcutaneous emphysema (TSE) originating from frontal, nasoethmoidal, and maxillary facial injuries with sinusal involvement in the emergency room setting.

PATIENTS AND METHODS

All patients with a fracture involving the paranasal sinuses were evaluated with regard to TSE occurrence. Data analysis extended to gender, age, etiology, fracture sites, TSE location, sinus involvement, treatment, and complications from April 1999 to December 2003. Evaluation methods included computed tomography scan and clinical evaluation.

RESULTS

A total of 390 patients sustaining 458 paranasal sinus fractures were included. TSE was observed in 29 patients (7.43%) patients (male-female ratio of 3.83:1, with a mean age of 36.71 +/- 15.71 years). The main etiologies were vehicle accidents and assaults. Isolated maxillary sinuses fractures were found in 17 cases (58.62%). Ethmoidal and maxillary fractures were associated with 9 cases (31.03%), and 1 (3.45%) case had maxillary and frontal fractures together. Ethmoidal, maxillary, and frontal fractures were found concomitantly in 2 (6.90%) cases. Periorbital emphysema was the most prevalent site of presentation, and edema (86.21%) and bone deformities (79.31%) were the most frequent findings associated with TSE. Conservative treatment was the prevalent treatment choice (55.17%), and 1 complication because of persistent pain was noted.

CONCLUSION

The results suggest that TSE of the face associated with paranasal sinus fractures maintained the clinical features of its fractures of origin. The ethmoidal sinuses were considered as the most prevalent etiologic site, and the periorbital region was responsible for addressing the higher incidence of SE following paranasal sinus fractures.