Seminars in Ophthalmology
ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage: http://www.tandfonline.com/loi/isio20
Orbital Emphysema Occurring During Weight Lifting Ozdemir Ozdemir To cite this article: Ozdemir Ozdemir (2014): Orbital Emphysema Occurring During Weight Lifting, Seminars in Ophthalmology, DOI: 10.3109/08820538.2013.874469 To link to this article: http://dx.doi.org/10.3109/08820538.2013.874469
Published online: 29 Jan 2014.
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Date: 05 November 2015, At: 15:45
Seminars in Ophthalmology, Early Online, 1–3, 2014 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2013.874469
C ASE REPORT
Orbital Emphysema Occurring During Weight Lifting Ozdemir Ozdemir
Downloaded by [University of Cambridge] at 15:45 05 November 2015
Department of Ophthalmology, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
ABSTRACT Although orbital emphysema is a recognized complication of orbital fractures involving any of the paranasal sinuses, it may develop without any fracture. A 23-year-old man presented with sudden left periorbital swelling during weight lifting in a fitness facility. On the left side, there was periorbital swelling with crepitus in palpation of subcutaneous tissue and conjunctival congestion. Computed tomography showed no fractures in the orbit. The patient was hospitalized. He was treated with empiric antibiotics and non-steroidal antiinflammatory drugs. In three days, the swelling and crepitus had almost disappeared. Seven days later, orbital emphysema had completely resolved. Keywords: Computed tomography, crepitus, periorbital swelling, trauma, weight lifting
INTRODUCTION
On physical examination, the patient’s vital signs were normal. On the left side, there was a periorbital swelling with crepitus in palpation of subcutaneous tissue and conjunctival congestion. Ocular movements and pupillary light reactions were normal. The best visual acuity was 10/10 in Snellen chart. Intraocular pressure measured with Goldman applanation tonometer was 12 mmhg. In biomicroscopic examination, the anterior segment and dilated fundus were normal. Right eye examination was normal. Computed tomography (CT) included paranasal sinuses was performed. Submassive subcutaneous emphysema in the left orbit was found. There were no fractures noted on the 1.5 mm sections of the orbit (Figures 2 and 3). It was concluded that the air came from the ethmoid sinuses. The patient was hospitalized for observation. No significant ocular damage was observed. Needle aspiration was found not to be necessary. Ice application, Semi-Fowler’s position, and avoidance of nose blowing and sneezing were advised. The patient was treated with empiric antibiotics (ceftriaxone 5 mg/kg per day and gentamicin 1 mg/kg per day) and a non-steroidal anti-inflammatory drug to protect him from periorbital and orbital infection due to wall
Orbital emphysema is a well-known complication of orbital fractures involving any of the paranasal sinuses. Emphysema occurs when free air goes into orbits. The air can originate from an internal source (endogenous) or an external source (exogenous). Endogenous emphysema is much more common, occurring in the setting of an orbital fracture, when an access route from the paranasal sinuses to the orbit is created. With nose blowing, coughing, or other forced exhalation, air is driven into the orbit. Orbital emphysema may be seen in cases of orbital fracture involving the ethmoid and sphenoid sinuses, especially when there is vigorous nose blowing.1–3
CASE REPORT The patient was a 23-year-old man. He was admitted to the hospital two hours after the accident. He presented with sudden left periorbital swelling following weight lifting in a fitness facility (Figure 1). He had no history of sinusitis, facial trauma, or previous surgery.
Received 8 June 2013; accepted 8 December 2013; published online 28 January 2014 Correspondence: Ozdemir Ozdemir, Go¨z Hastalıkları Poliklinig˘i, Zekai Tahir Burak Kadın Sag˘lıg˘ ı Eg˘itim Ve Ara¸stırma Hastanesi, Talatpa¸sa Bulvarı, Altındag˘, Ankara, Turkey. E-mail: [email protected]
1
2
O. Ozdemir
Downloaded by [University of Cambridge] at 15:45 05 November 2015
FIGURE 1. Periorbital swelling outside and echymosis around the left eye.
FIGURE 3. Coronal image in the bony window. There is no orbital wall fracture.
FIGURE 2. Axial image in the soft tissue window. There is a large subcutaneous emphysema in the left orbit and no orbital wall fracture.
fracture of the paranasal sinuses. In three days, the swelling and crepitus had almost disappeared, so antibiotics were stopped (Figure 4). Seven days later, orbital emphysema had completely resolved. This case has been reported in accordance with the ethical principles in the Declaration of Helsinki and written informed consent for publication was received from the patient.
DISCUSSION Trauma is the most common underlying etiology in orbital emphysema. Usually, orbital emphysema is seen in facial trauma associated with damage to the paranasal sinuses or facial bones. Sometimes, due to
FIGURE 4. The swelling had almost disappeared by the third day.
orbital wall fractures causing sneezing, coughing, or vomiting, rapid increases in the pressure of the upper respiratory tract are associated with barotraumas. The lamina papyracea (medial orbital wall), which is described as a weakest point of the orbital wall, is the most common site of orbital fractures for passing of air from paranasal sinuses.4–6 Orbital emphysema is usually diagnosed with patient history, physical examination, and orbital CT evaluation. Subconjunctival hemorrhage, crepitation, tenderness, and pain can be detected on physical examination. CT is the most acceptable method for detection and evaluation of orbital wall fractures. In this case, there was periorbital emphysema and crepitation but no subconjunctival hemorrhage or pain in ocular examination. Moreover, no fracture was detected in CT. Mathew et al. reported a case of orbital emphysema caused by compressed air injury. There Seminars in Ophthalmology
Downloaded by [University of Cambridge] at 15:45 05 November 2015
Orbital Emphysema was no orbital fracture in CT but the air was seen under conjunctiva in the superior and inferior fornix.7 We considered that the air causing orbital emphysema originated from the ethmoid sinuses, though there was no orbital wall fracture. There is no accepted approach to the management of orbital emphysema. Silver et al. studied orbital fractures secondary to blunt trauma and their complications, and proposed a treatment algorithm about orbital emphysema. They recommended prophylactic antibiotic management because of the consequences of a pathologic communication between the paranasal sinuses and the orbit secondary to blunt facial trauma.8 If a patient has a loss of visual acuity and/ or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve is very possible. Frenkel et al. suggested an intravenous loading dose of methylprednisolone 30 mg/kg, and a second 15-mg/kg dose two hours after the initial dose, followed by 15 mg/kg every six hours.9 When orbital emphysema shows signs of pressure, such as restricted ocular motility, sluggish pupillary reaction, disc edema, or decreased visual acuity, air drainage and/or direct decompression should be considered. It can be done effectively by simple underwater drainage of air by a 24-gauge needle or lateral canthotomy and cantholysis.10 Orbital emphysema may be associated with ethmoid fractures and the entrapped air increases the orbital pressures. This ophthalmic emergency should be treated urgently by aspiration of air or incision and drainage of the orbital spaces, or an irreversible loss of vision may result.11 In addition, orbital emphysema following fractures of the paranasal sinuses is a rare cause of optic nerve compression. Traumatic optic neuropathy following orbital fractures is due to air forced into the orbit through the fracture.12 Optic nerve sheath decompression is indicated in progressive traumatic optic neuropathy when an enlarged fluid-filled sheath has been demonstrated sonographically.9 The development of orbital emphysema without trauma is unusual. In this case, although the emphysema was severe, there was no orbital bone fracture, visual loss, or restriction of eye movement. The orbital
!
2014 Informa Healthcare USA, Inc.
3
emphysema was recovered without any intervention such as aspiration or incision. In conclusion, orbital emphysema may occur spontaneously during weight lifting.
DECLARATION OF INTEREST The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES 1. Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema: staging and acute management. Ophthalmology 1994;101:960–966. 2. Kuhn F, Pieramici DJ. Ocular Trauma: principles and Practice. New York: Thieme, 2002; 89–95. 3. Ibid., 392–405. 4. Mohan B, Singh KP. Bilateral subcutaneous orbital emphysema of orbit following nose blowing. J Laryngol Otol 2001; 115:319–320. 5. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839–1849. 6. Taguchi Y, Sakakibara Y, Uchida K, Kishi H. Orbital emphysema following nose blowing as a sequel of a snowboard-related head injury. Br J Sports Med 2004; 38(5):28. 7. Mathew S, Vasu U, Francis F, Nazareth C. Transconjunctival orbital emphysema caused by compressed air injury: a case report. Indian J Ophthalmol 2008; 56(3):247–249. 8. Silver HS, Fucci MJ, Flanagan JC, Lowry LD. Severe orbital infection as a complication of orbital fracture. Arch Otolaryngol Head Neck Surg 1992;118(8):845–848. 9. Frenkel RE, Spoor TC. Diagnosis and management of traumatic optic neuropathies. Adv Ophthalmic Plast Reconstr Surg 1987;6:71–90. 10. Sever M, Bu¨yu¨kyılmaz T. Orbital emphysema due to nose blowing. Turk J Med Sci 2009;39(1):143–145. 11. O’Donnell B. Orbital trauma. In: Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery. Collin R, Rose G, Eds., pp. 150–161; Hoboken, NJ: BMJ Books, 2001. 12. Carter KD, Nerad JA. Fluctuating visual loss secondary to orbital emphysema. Am J Ophthalmol 1987;104:664–665.
ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage: http://www.tandfonline.com/loi/isio20
Orbital Emphysema Occurring During Weight Lifting Ozdemir Ozdemir To cite this article: Ozdemir Ozdemir (2014): Orbital Emphysema Occurring During Weight Lifting, Seminars in Ophthalmology, DOI: 10.3109/08820538.2013.874469 To link to this article: http://dx.doi.org/10.3109/08820538.2013.874469
Published online: 29 Jan 2014.
Submit your article to this journal
Article views: 25
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isio20 Download by: [University of Cambridge]
Date: 05 November 2015, At: 15:45
Seminars in Ophthalmology, Early Online, 1–3, 2014 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2013.874469
C ASE REPORT
Orbital Emphysema Occurring During Weight Lifting Ozdemir Ozdemir
Downloaded by [University of Cambridge] at 15:45 05 November 2015
Department of Ophthalmology, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
ABSTRACT Although orbital emphysema is a recognized complication of orbital fractures involving any of the paranasal sinuses, it may develop without any fracture. A 23-year-old man presented with sudden left periorbital swelling during weight lifting in a fitness facility. On the left side, there was periorbital swelling with crepitus in palpation of subcutaneous tissue and conjunctival congestion. Computed tomography showed no fractures in the orbit. The patient was hospitalized. He was treated with empiric antibiotics and non-steroidal antiinflammatory drugs. In three days, the swelling and crepitus had almost disappeared. Seven days later, orbital emphysema had completely resolved. Keywords: Computed tomography, crepitus, periorbital swelling, trauma, weight lifting
INTRODUCTION
On physical examination, the patient’s vital signs were normal. On the left side, there was a periorbital swelling with crepitus in palpation of subcutaneous tissue and conjunctival congestion. Ocular movements and pupillary light reactions were normal. The best visual acuity was 10/10 in Snellen chart. Intraocular pressure measured with Goldman applanation tonometer was 12 mmhg. In biomicroscopic examination, the anterior segment and dilated fundus were normal. Right eye examination was normal. Computed tomography (CT) included paranasal sinuses was performed. Submassive subcutaneous emphysema in the left orbit was found. There were no fractures noted on the 1.5 mm sections of the orbit (Figures 2 and 3). It was concluded that the air came from the ethmoid sinuses. The patient was hospitalized for observation. No significant ocular damage was observed. Needle aspiration was found not to be necessary. Ice application, Semi-Fowler’s position, and avoidance of nose blowing and sneezing were advised. The patient was treated with empiric antibiotics (ceftriaxone 5 mg/kg per day and gentamicin 1 mg/kg per day) and a non-steroidal anti-inflammatory drug to protect him from periorbital and orbital infection due to wall
Orbital emphysema is a well-known complication of orbital fractures involving any of the paranasal sinuses. Emphysema occurs when free air goes into orbits. The air can originate from an internal source (endogenous) or an external source (exogenous). Endogenous emphysema is much more common, occurring in the setting of an orbital fracture, when an access route from the paranasal sinuses to the orbit is created. With nose blowing, coughing, or other forced exhalation, air is driven into the orbit. Orbital emphysema may be seen in cases of orbital fracture involving the ethmoid and sphenoid sinuses, especially when there is vigorous nose blowing.1–3
CASE REPORT The patient was a 23-year-old man. He was admitted to the hospital two hours after the accident. He presented with sudden left periorbital swelling following weight lifting in a fitness facility (Figure 1). He had no history of sinusitis, facial trauma, or previous surgery.
Received 8 June 2013; accepted 8 December 2013; published online 28 January 2014 Correspondence: Ozdemir Ozdemir, Go¨z Hastalıkları Poliklinig˘i, Zekai Tahir Burak Kadın Sag˘lıg˘ ı Eg˘itim Ve Ara¸stırma Hastanesi, Talatpa¸sa Bulvarı, Altındag˘, Ankara, Turkey. E-mail: [email protected]
1
2
O. Ozdemir
Downloaded by [University of Cambridge] at 15:45 05 November 2015
FIGURE 1. Periorbital swelling outside and echymosis around the left eye.
FIGURE 3. Coronal image in the bony window. There is no orbital wall fracture.
FIGURE 2. Axial image in the soft tissue window. There is a large subcutaneous emphysema in the left orbit and no orbital wall fracture.
fracture of the paranasal sinuses. In three days, the swelling and crepitus had almost disappeared, so antibiotics were stopped (Figure 4). Seven days later, orbital emphysema had completely resolved. This case has been reported in accordance with the ethical principles in the Declaration of Helsinki and written informed consent for publication was received from the patient.
DISCUSSION Trauma is the most common underlying etiology in orbital emphysema. Usually, orbital emphysema is seen in facial trauma associated with damage to the paranasal sinuses or facial bones. Sometimes, due to
FIGURE 4. The swelling had almost disappeared by the third day.
orbital wall fractures causing sneezing, coughing, or vomiting, rapid increases in the pressure of the upper respiratory tract are associated with barotraumas. The lamina papyracea (medial orbital wall), which is described as a weakest point of the orbital wall, is the most common site of orbital fractures for passing of air from paranasal sinuses.4–6 Orbital emphysema is usually diagnosed with patient history, physical examination, and orbital CT evaluation. Subconjunctival hemorrhage, crepitation, tenderness, and pain can be detected on physical examination. CT is the most acceptable method for detection and evaluation of orbital wall fractures. In this case, there was periorbital emphysema and crepitation but no subconjunctival hemorrhage or pain in ocular examination. Moreover, no fracture was detected in CT. Mathew et al. reported a case of orbital emphysema caused by compressed air injury. There Seminars in Ophthalmology
Downloaded by [University of Cambridge] at 15:45 05 November 2015
Orbital Emphysema was no orbital fracture in CT but the air was seen under conjunctiva in the superior and inferior fornix.7 We considered that the air causing orbital emphysema originated from the ethmoid sinuses, though there was no orbital wall fracture. There is no accepted approach to the management of orbital emphysema. Silver et al. studied orbital fractures secondary to blunt trauma and their complications, and proposed a treatment algorithm about orbital emphysema. They recommended prophylactic antibiotic management because of the consequences of a pathologic communication between the paranasal sinuses and the orbit secondary to blunt facial trauma.8 If a patient has a loss of visual acuity and/ or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve is very possible. Frenkel et al. suggested an intravenous loading dose of methylprednisolone 30 mg/kg, and a second 15-mg/kg dose two hours after the initial dose, followed by 15 mg/kg every six hours.9 When orbital emphysema shows signs of pressure, such as restricted ocular motility, sluggish pupillary reaction, disc edema, or decreased visual acuity, air drainage and/or direct decompression should be considered. It can be done effectively by simple underwater drainage of air by a 24-gauge needle or lateral canthotomy and cantholysis.10 Orbital emphysema may be associated with ethmoid fractures and the entrapped air increases the orbital pressures. This ophthalmic emergency should be treated urgently by aspiration of air or incision and drainage of the orbital spaces, or an irreversible loss of vision may result.11 In addition, orbital emphysema following fractures of the paranasal sinuses is a rare cause of optic nerve compression. Traumatic optic neuropathy following orbital fractures is due to air forced into the orbit through the fracture.12 Optic nerve sheath decompression is indicated in progressive traumatic optic neuropathy when an enlarged fluid-filled sheath has been demonstrated sonographically.9 The development of orbital emphysema without trauma is unusual. In this case, although the emphysema was severe, there was no orbital bone fracture, visual loss, or restriction of eye movement. The orbital
!
2014 Informa Healthcare USA, Inc.
3
emphysema was recovered without any intervention such as aspiration or incision. In conclusion, orbital emphysema may occur spontaneously during weight lifting.
DECLARATION OF INTEREST The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES 1. Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema: staging and acute management. Ophthalmology 1994;101:960–966. 2. Kuhn F, Pieramici DJ. Ocular Trauma: principles and Practice. New York: Thieme, 2002; 89–95. 3. Ibid., 392–405. 4. Mohan B, Singh KP. Bilateral subcutaneous orbital emphysema of orbit following nose blowing. J Laryngol Otol 2001; 115:319–320. 5. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839–1849. 6. Taguchi Y, Sakakibara Y, Uchida K, Kishi H. Orbital emphysema following nose blowing as a sequel of a snowboard-related head injury. Br J Sports Med 2004; 38(5):28. 7. Mathew S, Vasu U, Francis F, Nazareth C. Transconjunctival orbital emphysema caused by compressed air injury: a case report. Indian J Ophthalmol 2008; 56(3):247–249. 8. Silver HS, Fucci MJ, Flanagan JC, Lowry LD. Severe orbital infection as a complication of orbital fracture. Arch Otolaryngol Head Neck Surg 1992;118(8):845–848. 9. Frenkel RE, Spoor TC. Diagnosis and management of traumatic optic neuropathies. Adv Ophthalmic Plast Reconstr Surg 1987;6:71–90. 10. Sever M, Bu¨yu¨kyılmaz T. Orbital emphysema due to nose blowing. Turk J Med Sci 2009;39(1):143–145. 11. O’Donnell B. Orbital trauma. In: Fundamentals of Clinical Ophthalmology Plastic and Orbital Surgery. Collin R, Rose G, Eds., pp. 150–161; Hoboken, NJ: BMJ Books, 2001. 12. Carter KD, Nerad JA. Fluctuating visual loss secondary to orbital emphysema. Am J Ophthalmol 1987;104:664–665.
