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Delayed orbital emphysema as the manifestation of isolated medial orbital wall fracture
The Journal of Emergency Medicine, Vol. 31, No. 2, pp. 223–224, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $–see front matter
doi:10.1016/j.jemermed.2005.09.017
Visual Diagnosis in Emergency Medicine
DELAYED ORBITAL EMPHYSEMA AS THE MANIFESTATION OF ISOLATED MEDIAL ORBITAL WALL FRACTURE Tsung-Chien Lu,
MD,*
Patrick Chow-In Ko, MD,* Matthew Huei-Ming Ma, and Shyr-Chyr Chen, MD*†
MD, PHD,*†
*Department of Emergency Medicine, National Taiwan University Hospital, and †National Taiwan University College of Medicine, Taipei, Taiwan Reprint Address: Dr. Shyr-Chyr Chen, Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, No.7, Chung-Shan South Rd., Taipei 100, Taiwan
CASE REPORT
not to blow his nose. At a follow-up visit in the ophthalmology clinic 1 week later, the orbital emphysema had resolved uneventfully.
A 34-year-old male plumber presented to the Emergency Department (ED) for sudden onset of painful left infraorbital swelling when he was blowing his nose. Two days before presentation, the patient struck his left eye on a pipe protruding from a wall when abruptly turning his head to the left. Due to the hollow structure of the pipe, the injury was seemingly limited to an abrasion and contusion in the periorbital area with sparing of the globe. After the injury, he visited an ophthalmologic clinic and treatment with topical medications was prescribed. On physical examination, there was superficial abrasion over the left infraorbital region. The area appeared swollen with palpable crepitus. Visual acuity was 20/20 in both eyes. Extraocular movements and funduscopic examinations of both eyes were normal. An orbital computed tomography (CT) scan showed abnormal air accumulated in the infraorbital area (Figure 1). A small medial orbital wall (lamina papyracea) fracture was also noted with protrusion of soft tissue into the ethmoid sinus (Figure 2). Oral antibiotic and analgesic agents were prescribed and he was advised
DISCUSSION Orbital emphysema is usually a benign and transient complication of orbital fractures after blunt trauma. The condition is precipitated by forceful passage of air through a sino-orbital communication resulting from fractures of the orbital floor or medial wall (1). In this setting, delayed development of orbital emphysema after nose-blowing or sneezing is not uncommon. Although orbital trauma is the most common reported etiology, orbital emphysema may result from pulmonary barotrauma, infection, and operation (2). In our case, the development of a fracture to the lamina papyracea, the thinnest orbital bone, is likely a consequence of blunt forces directly towards the medial orbital wall when the patient abruptly turned his head to the left, creating an occult fracture of the lamina papyracea. The reason for the delayed presentation after nose-blowing or sneezing is believed to be the
Visual Diagnosis in Emergency Medicine is coordinated by Binh Ly, Medical Center, San Diego, California
RECEIVED: 19 January 2005; FINAL ACCEPTED: 15 September 2005
SUBMISSION RECEIVED:
3 June 2005; 223
MD,
of the University of California San Diego
224
action of suddenly increased intraorbital hydraulic pressure, which forces the originally non-displaced fracture to move and allow air communication between the orbit and the ethmoid sinuses. The diagnosis of orbital emphysema can be made by the history, accompanied by physical examination of the orbit, and confirmed by orbital CT scan. The classical aspect of the history is a forced expiratory effort, followed immediately by proptosis or orbital swelling hours to days after trauma to the orbit. Although there is no established standard for the management of orbital emphysema, conservative treatment with decongestants and instruction to avoid noseblowing will usually result in resolution of the entrapped air. There have been reports of vision impairing or threatening complications of orbital emphysema such as limited ocular movements, diplopia, central retinal artery occlusion, and compressive optic neuropathy (3– 6). Treatment of these more complicated injuries may include needle aspiration, lateral
T.-C. Lu et al.
Figure 2. Another view from the orbital CT scan showing fracture of the left lamina papyracea and some soft tissue protruded into the ethmoid sinus (arrow).
canthotomy, and surgical exploration that should be executed in consultation with a qualified ophthalmologist (7). REFERENCES
Figure 1. Orbital CT scan shows accumulation of air (arrow) in the left infraorbital area.
1. Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema. Staging and acute management. Ophthalmology 1994;101:960 – 6. 2. Zimmer-Galler IE, Bartley GB. Orbital emphysema: case reports and review of the literature. Mayo Clin Proc 1994;69:115–21. 3. Linberg JV. Orbital emphysema complicated by acute central retinal artery occlusion: case report and treatment. Ann Ophthalmol 1982; 14:747–9. 4. Fleishma JA, Beck RW, Hoffman RO. Orbital emphysema as an ophthalmologic emergency. Ophthalmology 1984;91:1389 –91. 5. Jordan DR, White GL Jr, Anderson RL, Thiese SM. Orbital emphysema: a potentially blinding complication following orbital fractures. Ann Emerg Med 1988;17:853–5. 6. Dobler AA, Nathenson AL, Cameron JD, Carpel ET, Janda AM, Pederson JE. A case of orbital emphysema as an ocular emergency. Retina 1993;13:166 – 8. 7. Segrest DR, Dortzbach RK. Medial orbital wall fractures: complications and management. Ophthal Plast Reconstr Surg 1989;5:75– 80.
doi:10.1016/j.jemermed.2005.09.017
Visual Diagnosis in Emergency Medicine
DELAYED ORBITAL EMPHYSEMA AS THE MANIFESTATION OF ISOLATED MEDIAL ORBITAL WALL FRACTURE Tsung-Chien Lu,
MD,*
Patrick Chow-In Ko, MD,* Matthew Huei-Ming Ma, and Shyr-Chyr Chen, MD*†
MD, PHD,*†
*Department of Emergency Medicine, National Taiwan University Hospital, and †National Taiwan University College of Medicine, Taipei, Taiwan Reprint Address: Dr. Shyr-Chyr Chen, Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, No.7, Chung-Shan South Rd., Taipei 100, Taiwan
CASE REPORT
not to blow his nose. At a follow-up visit in the ophthalmology clinic 1 week later, the orbital emphysema had resolved uneventfully.
A 34-year-old male plumber presented to the Emergency Department (ED) for sudden onset of painful left infraorbital swelling when he was blowing his nose. Two days before presentation, the patient struck his left eye on a pipe protruding from a wall when abruptly turning his head to the left. Due to the hollow structure of the pipe, the injury was seemingly limited to an abrasion and contusion in the periorbital area with sparing of the globe. After the injury, he visited an ophthalmologic clinic and treatment with topical medications was prescribed. On physical examination, there was superficial abrasion over the left infraorbital region. The area appeared swollen with palpable crepitus. Visual acuity was 20/20 in both eyes. Extraocular movements and funduscopic examinations of both eyes were normal. An orbital computed tomography (CT) scan showed abnormal air accumulated in the infraorbital area (Figure 1). A small medial orbital wall (lamina papyracea) fracture was also noted with protrusion of soft tissue into the ethmoid sinus (Figure 2). Oral antibiotic and analgesic agents were prescribed and he was advised
DISCUSSION Orbital emphysema is usually a benign and transient complication of orbital fractures after blunt trauma. The condition is precipitated by forceful passage of air through a sino-orbital communication resulting from fractures of the orbital floor or medial wall (1). In this setting, delayed development of orbital emphysema after nose-blowing or sneezing is not uncommon. Although orbital trauma is the most common reported etiology, orbital emphysema may result from pulmonary barotrauma, infection, and operation (2). In our case, the development of a fracture to the lamina papyracea, the thinnest orbital bone, is likely a consequence of blunt forces directly towards the medial orbital wall when the patient abruptly turned his head to the left, creating an occult fracture of the lamina papyracea. The reason for the delayed presentation after nose-blowing or sneezing is believed to be the
Visual Diagnosis in Emergency Medicine is coordinated by Binh Ly, Medical Center, San Diego, California
RECEIVED: 19 January 2005; FINAL ACCEPTED: 15 September 2005
SUBMISSION RECEIVED:
3 June 2005; 223
MD,
of the University of California San Diego
224
action of suddenly increased intraorbital hydraulic pressure, which forces the originally non-displaced fracture to move and allow air communication between the orbit and the ethmoid sinuses. The diagnosis of orbital emphysema can be made by the history, accompanied by physical examination of the orbit, and confirmed by orbital CT scan. The classical aspect of the history is a forced expiratory effort, followed immediately by proptosis or orbital swelling hours to days after trauma to the orbit. Although there is no established standard for the management of orbital emphysema, conservative treatment with decongestants and instruction to avoid noseblowing will usually result in resolution of the entrapped air. There have been reports of vision impairing or threatening complications of orbital emphysema such as limited ocular movements, diplopia, central retinal artery occlusion, and compressive optic neuropathy (3– 6). Treatment of these more complicated injuries may include needle aspiration, lateral
T.-C. Lu et al.
Figure 2. Another view from the orbital CT scan showing fracture of the left lamina papyracea and some soft tissue protruded into the ethmoid sinus (arrow).
canthotomy, and surgical exploration that should be executed in consultation with a qualified ophthalmologist (7). REFERENCES
Figure 1. Orbital CT scan shows accumulation of air (arrow) in the left infraorbital area.
1. Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema. Staging and acute management. Ophthalmology 1994;101:960 – 6. 2. Zimmer-Galler IE, Bartley GB. Orbital emphysema: case reports and review of the literature. Mayo Clin Proc 1994;69:115–21. 3. Linberg JV. Orbital emphysema complicated by acute central retinal artery occlusion: case report and treatment. Ann Ophthalmol 1982; 14:747–9. 4. Fleishma JA, Beck RW, Hoffman RO. Orbital emphysema as an ophthalmologic emergency. Ophthalmology 1984;91:1389 –91. 5. Jordan DR, White GL Jr, Anderson RL, Thiese SM. Orbital emphysema: a potentially blinding complication following orbital fractures. Ann Emerg Med 1988;17:853–5. 6. Dobler AA, Nathenson AL, Cameron JD, Carpel ET, Janda AM, Pederson JE. A case of orbital emphysema as an ocular emergency. Retina 1993;13:166 – 8. 7. Segrest DR, Dortzbach RK. Medial orbital wall fractures: complications and management. Ophthal Plast Reconstr Surg 1989;5:75– 80.