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

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.

Orbital Blowout Fracture and Orbital Emphysema caused by Nose Blowing

A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted.

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.

The Dangers of Sneezing: A Review of Injuries

BACKGROUND

Sneezing is an almost universal daily phenomenon as a reflex to evacuate irritants from the nasal cavities. An autonomic-controlled buildup of intrathoracic pressure against a closed glottis followed by sudden release results in a burst of 1 kPa of air through the upper airway. Active intervention to limit a sneeze can be deleterious. Closure of the airway during a sneeze can result in over 20 times the airway pressures resulting in a variety of untoward events. This review summarizes all reported injuries that occurred as the result of a sneeze.

OBJECTIVE

The objective of this review is to summarize the risks of closed-airway sneezing and determine if there are any trends which can help understand such injuries.

METHODS

A comprehensive literature review was performed from 1948 to 2018 to identify all reports of sneeze-related injuries. Information was compiled from reports to gain insights into comorbidities and risk factors for sneeze injuries.

RESULTS

There were 52 unique reports of sneeze-related injuries in the literature that were categorized into 6 areas of injury: intrathoracic, laryngeal/pharyngeal, ocular/orbital, intracranial/neurological, otologic, and other. The mean age of subjects who suffered a sneeze injury was 40 years old (range: 15-84 years), with 81% being male gender. Thirty percent had a risk factor for injury of prior trauma (5) or respiratory compromise (5).

CONCLUSION

A variety of injuries can occur during a sneeze, especially when a closed-airway sneeze is attempted, and high Valsalva pressure is transmitted to the other systems. Men are more at risk for these injuries with the majority occurring in patients with no known risk factor. When triggered, a sneeze should be allowed to proceed without intervention to prevent associated injuries.

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)

Nontraumatic orbital floor fracture after nose blowing

A 40-year-old woman with no history of trauma or prior surgery presented to the emergency department with headache and left eye pain after nose blowing. Noncontrast maxillofacial computed tomography examination revealed an orbital floor fracture that ultimately required surgical repair. There are nontraumatic causes of orbital blowout fractures, and imaging should be obtained irrespective of trauma history.