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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 503-506 |
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Orbital emphysema: A case series and review of literature
Chandana Chakroborti1, Banka A Megha2, Soumi Naskar1, Sonia R Thomas2
1 Regional Institute of Ophthalmology, Medical College, Kolkata, West Bengal, India
2 Ophthalmology, Regional Institute of Ophthalmology, Medical College, Kolkata, West Bengal, India
| Date of Submission | 14-Dec-2022 |
| Date of Acceptance | 07-Feb-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Banka A Megha
C/O Anju Kedia, Anmol Kriti, P28A, CIT Road Scheme VIM, Opposite Pantaloons, Kankurgachi, Kolkata - 700 054, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_3257_22
Orbital emphysema (OE) is an uncommon, benign, and self-limiting condition that results from trapping of air in loose periorbital subcutaneous tissues. We report a series of five cases of OE, four post traumatic, and one after forceful nose blowing. They presented with acute periorbital swelling. The clinical diagnosis was confirmed on imaging promptly. They were counseled to keep a keen eye for any signs of deterioration and kept on close follow-up. Some key clinical and radiological clues which indicated a relatively low risk of deterioration were noted, so they were conservatively managed with cold compression, avoidance of nose blowing/sneezing, nasal decongestants, oral antibiotics, and anti-inflammatories. Complete resolution of symptoms occurred within 2–3 weeks. Timely diagnosis, thorough patient counseling, conservative management, close monitoring, and expedient surgical intervention on deterioration are keystones in OE management.
Keywords: Conservative management, orbital emphysema, sneezing, trauma
How to cite this article:
Chakroborti C, Megha BA, Naskar S, Thomas SR. Orbital emphysema: A case series and review of literature. Indian J Ophthalmol Case Rep 2023;3:503-6 |
How to cite this URL:
Chakroborti C, Megha BA, Naskar S, Thomas SR. Orbital emphysema: A case series and review of literature. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:503-6. Available from: https://www.ijoreports.in/text.asp?2023/3/2/503/375031 |
Orbital emphysema (OE) is seen in cases with a history of sinusitis, facial trauma, or surgery.[1] The clinical picture usually is a sudden onset periorbital swelling which may or may not be associated with pain depending on the cause. Mild to moderate cases need close observation and conservative management, while deteriorating cases necessitate immediate surgical intervention. We report a series of five cases of OE that were diagnosed clinically and confirmed on imaging. They achieved complete resolution of symptoms on mere conservative management [Figure 1]c. | Figure 1: (a) Case 1 presentation 2 days after blunt trauma. (b) NCCT showing orbital emphysema (yellow arrow) near the right superior orbital margin. (c) Complete resolution of swelling after 2 weeks. (d) NCCT showing orbital emphysema (yellow arrow) and a right orbital medial wall fracture (red arrow)
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| Case Series | |  |
We report a series of five male (M) patients with OE [Table 1]. They presented with sudden onset periorbital and lid swelling with palpable crepitations. Cases 1–4 gave a history of blunt trauma and Case 5 of forceful nose blowing during his bath, one day back. There was no complaint of diminution of vision (DOV) nor any history of recent surgery or sinusitis.
None of the patients showed significantly reduced VA, signs of increased intraorbital pressure, sluggish pupillary reaction or relative afferent pupillary dilatation and/or disc edema. Periorbital and palpebral crepitations were present in all patients, which led to the diagnosis of OE which was confirmed on noncontrast computed tomography (NCCT). Patients were advised to avoid forceful blowing of the nose and sneezing and to maintain a supine position. They were prescribed nasal decongestants, oral antibiotics, and anti-inflammatory agents. They were asked to follow up within 48 h or immediately on any worsening of symptoms. Follow-up continued till the symptoms resolved. Three patients showed complete resolution of their symptoms after two weeks and two patients, over three weeks. The best-corrected visual acuity of all patients at the end of two weeks was 6/6.
| Discussion | | |
OE results from forceful air entry into the orbital soft tissue spaces following an orbital fracture. Rarer causes include infection by gas-producing organisms, pulmonary barotrauma, injury from compressed-air hoses, complications from surgery, sneezing, air travel and Boerhaave's syndrome.[2],[3] Isolated medial wall (Lamina Papyracea) fractures occur in 10–30% of cases of orbital trauma[2] and is the most common site of bony defect for passage of air from paranasal sinuses[1] as also seen in Case 1, [Figure 1]d.
OE can be classified as explained by Hunts et al.[4],[5][Table 2].
NCCT is effective in identifying the anatomic location of air when OE is suspected, as was seen in all five cases in our series [Figure 1]b, [Figure 2]b and [Figure 2]d.[2] Subcutaneous air restricted to the eyelid is classified as palpebral emphysema. Orbitalpalpebral emphysema occurs when orbital pressure increases beyond the mechanical strength of the orbital septum and air passes freely from the orbit into the eyelid, which effectively rules out any risk of orbital compartment syndrome.[2] All five cases in our series are orbitalpalpebral variants of OE, which explains the low risk of deterioration and the importance of conservative management. The most common sign in OE is swollen eyelid with crepitus. The second common sign is extraocular movement restriction. If supraduction limitation is noted with isolated medial wall fracture and superior OE with superior rectus muscle deviation, conservative management can be a good choice for spontaneous recovery regardless of soft tissue inflammation.[6] OE can initially be commonly mistaken as preseptal or orbital cellulitis if crepitations have been missed. However, it is worth noting that in the case of the latter, the patient is evidently a sicker patient (with or without fever) and in more pain than the former. Thereby implying that these simple clues should not be overlooked when examining a case of painful lid/orbital swelling for a faster and more accurate diagnosis and consequently thorough management. In rare cases, orbital soft tissues may block the bony defect and produce a one-way check valve, allowing air to enter but not to leave the orbit, causing the acute onset of elevated orbital tension. The increased orbital pressure could result in proptosis, impaired ocular movement, sudden DOV, and increase in pain. These symptoms could be due to acute orbital compartment syndrome, Central Retinal Artery Occlusion (CRAO), compressive/ischemic optic neuropathy. Vision-threatening OE often requires rapid surgical decompression, such as lateral canthotomy or cantholysis, and open decompression. Needle decompression has been reported to be a simple, rapid, and effective technique for OE.[1],[7],[8] | Figure 2: (a) Case 2 presentation 1 day after blunt trauma. (b) Case 2 NCCT showing left frontal sinus communication with orbital emphysema near the left superior orbital margin (Red arrow). (c) Case 5 presentation 1 day after forceful nose blowing. (d) Case 5 NCCT showing orbital emphysema near the left superior and medial orbital margins (yellow arrow)
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| Conclusion | | |
Identifying OE on the presentation by maintaining a high degree of suspicion for specific clinical findings like a crepitus in an acute, periorbital swelling and careful correlation with history is the first step to successfully managing a case of OE. Following this, confirmation on imaging on NCCT for precise location and extent is crucial for further plan of management. Thorough patient counseling and close follow-up, along with recognition of need for urgent surgical intervention on time in this largely self-limiting and uncommon condition, can prove to be not only sight saving but can also restore a VA of up to 6/6 in most cases with complete resolution of other symptoms. The purpose of this article is to stress on the recognition of this uncommon condition in time to enable simple conservative management and timely surgical intervention to prevent potential visual loss.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Shah N. Spontaneous subcutaneous orbital emphysema following forceful nose blowing: Treatment options. Indian J Ophthalmol 2007;55:395.  [ PUBMED] [Full text] |
| 2. | Gauguet JM, Lindquist PA, Shaffer K. Orbital emphysema following ocular trauma and sneezing. Radiol Case Rep 2008;3:124. doi: 10.2484/rcr.v3i1.124. |
| 3. | Çetinkaya YF, Çetinkaya S. Orbital Emphysema Following A Forceful Blowing: A Case Report. Journal of Emergency Medicine Case Reports 2021;12:103-5. |
| 4. | Gauguet JM, Lindquist PA, Shaffer K. Orbital emphysema following ocular trauma and sneezing. Radiology Case Reports 2008;3:124. |
| 5. | Shameer A, Pushker N, Lokdarshi G, Basheer S, Bajaj MS. Emergency decompression of orbital emphysema with elevated intraorbital pressure. J Emerg Med 2017;53:405-7. |
| 6. | Moon H, Kim Y, Wi JM, Chi M. Morphological characteristics and clinical manifestations of orbital emphysema caused by isolated medial orbital wall fractures. Eye 2016;30:582-7. |
| 7. | Lin C-Y, Tsai C-C, Kao S-C, Kau H-C, Lee F-L. Needle decompression in a patient with vision-threatening orbital emphysema. Taiwan J Ophthalmol 2016;6:93-5. [ PUBMED] [Full text] |
| 8. | Benharbit M, Karim A, Lazreq M, Mohcine Z. [Emergency treatment of post-traumatic orbital emphysema: A case report]. J Fr D'ophtalmol 2003;26:957-9. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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