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Tension pneumo-orbit secondary to minor blunt force trauma
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ARTICLE IN PRESS
ANORL-940; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
Available online at
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Case report
Tension pneumo-orbit secondary to minor blunt force trauma A. Ashman a,∗ , J.H. Norris b , K. Chaidas c a
ENT Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, OX3 9DU Oxford, United Kingdom Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom c John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom b
a r t i c l e
i n f o
Keywords: Ophthalmology Orbital fractures Exophthalmos
a b s t r a c t Introduction: Tension pneumo-orbit is a rare but eye-threatening sequelae of orbital trauma. Minimal trauma to the lamina papyracea can result in a valve effect leading to rapid-onset proptosis and optic nerve compression in the absence of a haematoma. Case report: We describe a case of medial orbital wall fracture in a 35-year-old lady following a minor fall at home. She presented with severe proptosis of the left eye. Imaging showed marked pneumo-orbit, which was managed definitively by endoscopic orbital decompression. Discussion: Tension pneumo-orbit requires prompt recognition and surgical decompression. An endonasal approach may be used to decompress the orbit via the medial wall. © 2019 Published by Elsevier Masson SAS.
1. Introduction Accumulation of air within the soft tissues of the orbit is a recognized complication of orbital fracture, usually manifesting as surgical emphysema. This can occasionally cause orbital compartment syndrome, necessitating decompression; however, many cases can be managed conservatively as the air is reabsorbed over time. In contrast, the formation of a tension pneumo-orbit is associated with rapid-onset compression of the orbital contents and requires emergent surgical intervention [1]. We describe a case of tension pneumo-orbit secondary to orbital trauma, along with its surgical management. 2. Case report A 35-year-old lady tripped over the power cord to her vacuum cleaner, sustaining a minor blow to the midfacial region. She did not notice any head injury and continued as normal. After a short while, she noticed discomfort in her left eye, necessitating removal of her contact lens. Over a four-hour period, her left eye became markedly proptosed, which was exacerbated by nose blowing, and she developed significant diplopia (Fig. 1). On arrival in the Emergency Department, she was referred to the ophthalmology department. Clinical assessment revealed marked proptosis with an almost complete external ophthalmople-
∗ Corresponding author. E-mail address: [email protected] (A. Ashman).
Fig. 1. A clinical photograph of the left eye showing marked proptosis.
gia. Visual acuity in the left eye was reduced to perception-of-light with a relative afferent pupillary defect. The working diagnosis was retrobulbar haemorrhage, and immediate management involved lateral canthotomy and inferior cantholysis. Following a lack of improvement, computed tomography of the head was performed revealing a defect in the left lamina
https://doi.org/10.1016/j.anorl.2019.03.006 1879-7296/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006
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ARTICLE IN PRESS A. Ashman et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
assessment three months after surgery revealed normal findings with further improvement of vision to 6/9 (Fig. 3). 3. Discussion
Fig. 2. An axial CT slice showing extensive surgical emphysema of the orbit.
Fig. 3. A clinical photograph of the left eye showing resolution of the proptosis.
papyracea, providing a communication between the ethmoid air cells and the orbit. There was extensive surgical emphysema suggesting tension in the orbit and secondary optic nerve compression (Fig. 2). The patient was immediately taken to the operating theatre. Initially, an external decompression was performed by the ophthalmologists via an upper eyelid skin crease incision. A drain was placed in the superior orbit with slight improvement of orbital tension. The ENT team then proceeded with a middle meatal antrostomy and ethmoidectomy, allowing identification and partial removal of the fractured lamina papyracea. A strut of bone was preserved anteriorly at the juncture of the inferior and medial orbital walls to avoid excessive displacement of the globe and minimize the risk of diplopia. Endonasal packing was not used. As a result of decompression, the globe returned to a normal position within the orbit. The patient was observed for three days and was given a reducing dose of intravenous dexamethasone over this time. There was marked improvement in the left eye with near complete resolution of the proptosis and ophthalmoplegia. Vision improved to 6/12 by the time of discharge. Prophylactic antibiotics were given for seven days postoperatively and the patient was instructed to avoid nose blowing for two weeks. Follow-up
Fractures of the medial orbital wall are uncommon and occur as a result of trauma when force is transmitted from the orbital rim or through the globe. Enophthalmos is likely to occur due to increased orbital volume or prolapse of orbital tissues. Periorbital emphysema may occur following blunt trauma, but this is usually managed conservatively [2]. Pneumo-orbit with resultant exophthalmos is unusual and may be mistaken for inferior rectus entrapment as it can result in the same presentation of restricted upgaze following injury to the orbit [3]. Furthermore, it has also been described occurring secondary an orbital floor fracture [4]. Computed tomography is therefore the investigation of choice to demonstrate the presence and extent of the fracture and pneumo-orbit and guide the surgical approach. Tension pneumo-orbit occurs when the orbital wall acts as a one-way valve, admitting air and then retaining it under tension. This can cause rapid-onset compression of the optic nerve and/or central retinal artery, requiring rapid management. The tensioning can be worsened by increased intranasal pressure caused by sneezing or nose blowing. Similarly, the ongoing delivery of oxygen via nasopharyngeal cannulae has been described as exacerbating tension pneumo-orbit that occurred in two paediatric patients following traumatic insertion of the cannulae [5]. Whereas orbital emphysema may be managed with needle aspiration, surgical decompression of the orbit appears to be necessary when intra-orbital compartment syndrome is present [6]. Needle aspiration of the orbit has been described in one case, but this was followed 12 hours later by recurrence of proptosis and eventual surgical decompression [1]. Decompression may be via an open (transorbital) or endoscopic (endonasal) approach. The latter makes use of endoscopic sinus surgery techniques familiar to ENT surgeons, with the benefits of avoidance of scar and potentially clearer visualization of the operative site under magnification. It is notable in the one existing case in the literature [1], the onset of tension pneumo-orbit was gradual, leading to the patient presenting five days after the initial injury. We believe our case is exceptional in that a mild blunt trauma to the medial orbital wall precipitated a severe and rapidly progressing proptosis with significant visual impairment. In our case, rapid identification of the tension pneumo-orbit and prompt surgical management required close collaboration between specialties, and led to a good outcome for the patient. 4. Conclusion Tension pneumo-orbit is a rare but eye-threatening condition that can occur following relatively minor trauma to the orbit. It requires prompt recognition and management with orbital decompression. This may be performed via open or endoscopic approaches, with rapid improvement in the eye’s condition following the procedure. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements None.
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006
G Model ANORL-940; No. of Pages 3
ARTICLE IN PRESS A. Ashman et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
References [1] Al-Shammari L, Majithia A, Adams A, Chatrath P. Tension pneumo-orbit treated by endoscopic, endonasal decompression: case report and literature review. J Laryngol Otol 2008:E8, http://dx.doi.org/10.1017/S002221510700165X. [2] Key SJ, Ryba F, Holmes S, Manisali M. Orbital emphysema – the need for surgical intervention. J Craniomaxillofac Surg 2008;36(8):473–6, http://dx.doi.org/ 10.1016/j.jcms.2008.04.004. [3] Burt B, Jamieson M, Sloan B. Medial wall fracture-induced pneumo-orbita mimicking inferior rectus entrapment. Am J Emerg Med 2010;28(1):119e1–3, http://dx.doi.org/10.1016/j.ajem.2009.04.040.
3
[4] Tomasetti P, Jacbosen C, Gander T, Zemann W. Emergency decompression of tension retrobulbar emphysema secondary to orbital floor fracture. J Surg Case Rep 2013;2013(3), http://dx.doi.org/10.1093/jscr/rjt011. [5] O’Brien BJ, Rosenfeld JV, Elder JE. Tension pneumo-orbitus and pneumocephalus induced by a nasal oxygen cannula: report on two paediatric cases. J Paediatr Child Health 2000;36(5):511–4, http://dx.doi.org/10. 1046/j.1440-1754.2000.00550.x. [6] García-Medina JJ, García-Medina M, Pinazo-Durán MD. Severe orbitopalpebral emphysema after nose blowing requiring emergency decompression. Eur J Ophthalmol 2006;16(2):339–42 [10.1177%2F112067210601600224].
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006
ARTICLE IN PRESS
ANORL-940; No. of Pages 3
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Case report
Tension pneumo-orbit secondary to minor blunt force trauma A. Ashman a,∗ , J.H. Norris b , K. Chaidas c a
ENT Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, OX3 9DU Oxford, United Kingdom Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom c John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom b
a r t i c l e
i n f o
Keywords: Ophthalmology Orbital fractures Exophthalmos
a b s t r a c t Introduction: Tension pneumo-orbit is a rare but eye-threatening sequelae of orbital trauma. Minimal trauma to the lamina papyracea can result in a valve effect leading to rapid-onset proptosis and optic nerve compression in the absence of a haematoma. Case report: We describe a case of medial orbital wall fracture in a 35-year-old lady following a minor fall at home. She presented with severe proptosis of the left eye. Imaging showed marked pneumo-orbit, which was managed definitively by endoscopic orbital decompression. Discussion: Tension pneumo-orbit requires prompt recognition and surgical decompression. An endonasal approach may be used to decompress the orbit via the medial wall. © 2019 Published by Elsevier Masson SAS.
1. Introduction Accumulation of air within the soft tissues of the orbit is a recognized complication of orbital fracture, usually manifesting as surgical emphysema. This can occasionally cause orbital compartment syndrome, necessitating decompression; however, many cases can be managed conservatively as the air is reabsorbed over time. In contrast, the formation of a tension pneumo-orbit is associated with rapid-onset compression of the orbital contents and requires emergent surgical intervention [1]. We describe a case of tension pneumo-orbit secondary to orbital trauma, along with its surgical management. 2. Case report A 35-year-old lady tripped over the power cord to her vacuum cleaner, sustaining a minor blow to the midfacial region. She did not notice any head injury and continued as normal. After a short while, she noticed discomfort in her left eye, necessitating removal of her contact lens. Over a four-hour period, her left eye became markedly proptosed, which was exacerbated by nose blowing, and she developed significant diplopia (Fig. 1). On arrival in the Emergency Department, she was referred to the ophthalmology department. Clinical assessment revealed marked proptosis with an almost complete external ophthalmople-
∗ Corresponding author. E-mail address: [email protected] (A. Ashman).
Fig. 1. A clinical photograph of the left eye showing marked proptosis.
gia. Visual acuity in the left eye was reduced to perception-of-light with a relative afferent pupillary defect. The working diagnosis was retrobulbar haemorrhage, and immediate management involved lateral canthotomy and inferior cantholysis. Following a lack of improvement, computed tomography of the head was performed revealing a defect in the left lamina
https://doi.org/10.1016/j.anorl.2019.03.006 1879-7296/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006
G Model ANORL-940; No. of Pages 3 2
ARTICLE IN PRESS A. Ashman et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
assessment three months after surgery revealed normal findings with further improvement of vision to 6/9 (Fig. 3). 3. Discussion
Fig. 2. An axial CT slice showing extensive surgical emphysema of the orbit.
Fig. 3. A clinical photograph of the left eye showing resolution of the proptosis.
papyracea, providing a communication between the ethmoid air cells and the orbit. There was extensive surgical emphysema suggesting tension in the orbit and secondary optic nerve compression (Fig. 2). The patient was immediately taken to the operating theatre. Initially, an external decompression was performed by the ophthalmologists via an upper eyelid skin crease incision. A drain was placed in the superior orbit with slight improvement of orbital tension. The ENT team then proceeded with a middle meatal antrostomy and ethmoidectomy, allowing identification and partial removal of the fractured lamina papyracea. A strut of bone was preserved anteriorly at the juncture of the inferior and medial orbital walls to avoid excessive displacement of the globe and minimize the risk of diplopia. Endonasal packing was not used. As a result of decompression, the globe returned to a normal position within the orbit. The patient was observed for three days and was given a reducing dose of intravenous dexamethasone over this time. There was marked improvement in the left eye with near complete resolution of the proptosis and ophthalmoplegia. Vision improved to 6/12 by the time of discharge. Prophylactic antibiotics were given for seven days postoperatively and the patient was instructed to avoid nose blowing for two weeks. Follow-up
Fractures of the medial orbital wall are uncommon and occur as a result of trauma when force is transmitted from the orbital rim or through the globe. Enophthalmos is likely to occur due to increased orbital volume or prolapse of orbital tissues. Periorbital emphysema may occur following blunt trauma, but this is usually managed conservatively [2]. Pneumo-orbit with resultant exophthalmos is unusual and may be mistaken for inferior rectus entrapment as it can result in the same presentation of restricted upgaze following injury to the orbit [3]. Furthermore, it has also been described occurring secondary an orbital floor fracture [4]. Computed tomography is therefore the investigation of choice to demonstrate the presence and extent of the fracture and pneumo-orbit and guide the surgical approach. Tension pneumo-orbit occurs when the orbital wall acts as a one-way valve, admitting air and then retaining it under tension. This can cause rapid-onset compression of the optic nerve and/or central retinal artery, requiring rapid management. The tensioning can be worsened by increased intranasal pressure caused by sneezing or nose blowing. Similarly, the ongoing delivery of oxygen via nasopharyngeal cannulae has been described as exacerbating tension pneumo-orbit that occurred in two paediatric patients following traumatic insertion of the cannulae [5]. Whereas orbital emphysema may be managed with needle aspiration, surgical decompression of the orbit appears to be necessary when intra-orbital compartment syndrome is present [6]. Needle aspiration of the orbit has been described in one case, but this was followed 12 hours later by recurrence of proptosis and eventual surgical decompression [1]. Decompression may be via an open (transorbital) or endoscopic (endonasal) approach. The latter makes use of endoscopic sinus surgery techniques familiar to ENT surgeons, with the benefits of avoidance of scar and potentially clearer visualization of the operative site under magnification. It is notable in the one existing case in the literature [1], the onset of tension pneumo-orbit was gradual, leading to the patient presenting five days after the initial injury. We believe our case is exceptional in that a mild blunt trauma to the medial orbital wall precipitated a severe and rapidly progressing proptosis with significant visual impairment. In our case, rapid identification of the tension pneumo-orbit and prompt surgical management required close collaboration between specialties, and led to a good outcome for the patient. 4. Conclusion Tension pneumo-orbit is a rare but eye-threatening condition that can occur following relatively minor trauma to the orbit. It requires prompt recognition and management with orbital decompression. This may be performed via open or endoscopic approaches, with rapid improvement in the eye’s condition following the procedure. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements None.
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006
G Model ANORL-940; No. of Pages 3
ARTICLE IN PRESS A. Ashman et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2019) xxx–xxx
References [1] Al-Shammari L, Majithia A, Adams A, Chatrath P. Tension pneumo-orbit treated by endoscopic, endonasal decompression: case report and literature review. J Laryngol Otol 2008:E8, http://dx.doi.org/10.1017/S002221510700165X. [2] Key SJ, Ryba F, Holmes S, Manisali M. Orbital emphysema – the need for surgical intervention. J Craniomaxillofac Surg 2008;36(8):473–6, http://dx.doi.org/ 10.1016/j.jcms.2008.04.004. [3] Burt B, Jamieson M, Sloan B. Medial wall fracture-induced pneumo-orbita mimicking inferior rectus entrapment. Am J Emerg Med 2010;28(1):119e1–3, http://dx.doi.org/10.1016/j.ajem.2009.04.040.
3
[4] Tomasetti P, Jacbosen C, Gander T, Zemann W. Emergency decompression of tension retrobulbar emphysema secondary to orbital floor fracture. J Surg Case Rep 2013;2013(3), http://dx.doi.org/10.1093/jscr/rjt011. [5] O’Brien BJ, Rosenfeld JV, Elder JE. Tension pneumo-orbitus and pneumocephalus induced by a nasal oxygen cannula: report on two paediatric cases. J Paediatr Child Health 2000;36(5):511–4, http://dx.doi.org/10. 1046/j.1440-1754.2000.00550.x. [6] García-Medina JJ, García-Medina M, Pinazo-Durán MD. Severe orbitopalpebral emphysema after nose blowing requiring emergency decompression. Eur J Ophthalmol 2006;16(2):339–42 [10.1177%2F112067210601600224].
Please cite this article in press as: Ashman A, et al. Tension pneumo-orbit secondary to minor blunt force trauma. European Annals of Otorhinolaryngology, Head and Neck diseases (2019), https://doi.org/10.1016/j.anorl.2019.03.006