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Case presentation

A 58-year-old Caucasian woman awoke with a blocked nose. She experienced a sudden right eyelid swelling with diplopia when blowing one nostril while blocking the other with her finger ( Fig. 1 ). Her medical and family histories were unremarkable except for chronic seasonal sinusitis. She denied history of smoking, alcohol consumption, and previous facial trauma and rhinosinusal surgery.

Clinical picture showing swelling and ecchymosis of the right eyelid.

On examination, the patient had painful swelling and ecchymosis of the right eyelid, coupled with restricted ocular movements of the affected eye. Palpation revealed crepitus over the right eyelid with no evidence of sensory abnormality. She was diplopic in upgaze. Visual acuity was normal bilaterally (both eyes: 0.8 Diopter), but the right visual field was reduced due to marked palpebral swelling. Pupils were equal and reactive to light with no afferent defect. Fundoscopy examination revealed no abnormality, and initial Hertel exophthalmometry result was 18-87-19.

Computed tomography (CT) showed large volume of air within the right eyelid and orbital cavity. There was also discontinuity of the right orbital floor with minimal prolapse of the orbital soft tissue into the maxillary antrum ( Figs. 2–4 ).

Axial computed tomography showing air within the right periorbital region with a small ethmoidal fracture.

Coronal computed tomography showing large volume of air within the right eyelid.

Coronal computed tomography showing air within the right orbital cavity. Discontinuity of the right orbital floor with minimal prolapse of the orbital soft tissue into the maxillary antrum, and bleeding and thickening of the right maxillary antral mucosa are evident.

What is your diagnosis?

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Diagnosis: Orbital floor fracture and emphysema (OFFE) caused by nose blowing

Orbital emphysema (OEm) refers to abnormal condition in which air is present within the fascial layers of the orbital and periorbital region. It is encountered in up to 50% of fractures involving paranasal sinuses and orbital walls . A traumatic communication with the paranasal sinuses allows air to enter the orbit and accumulate within the soft tissues. Orbital tissue such as fat may occlude the bony breach and acts as a one-way valve across the fracture site permitting air to enter the orbit, but not to leave it . However, sneezing, coughing, vomiting, nose blowing, and pressure change during air travel can also cause OEm, even in the absence of mechanical trauma . Rarer causes include necrotizing fasciitis and postseptal cellulitis caused by a gas-producing microorganism .

Our patient suffered from OFFE due to nose blowing without blunt trauma. To the best of our knowledge, there have been only six other similar reported cases . Three theories commonly used to explain the mechanism of orbital fracture (OF) include (1) globe-to-wall contact theory, (2) hydraulic theory, and (3) bone conduction theory . According to the hydraulic theory, nose blowing (“bushman’s hanky” in this case) increases intranasal pressure (INP), which is transmitted to the orbit through the dehiscent or broken lamina papyracea and/or lacerated orbital wall . In normal subjects, the increased INP during nose blowing may be up to 9 times higher than during sneezing (75 vs. up to 8.4 mmHg), and very high in chronic sinusitis patients (up to 181.5 mmHg) .

In fractures of the medial orbital wall, the pressure necessary to produce an OEm is less in aged subjects (10–15 mmHg) compared to the young counterpart (70–100 mmHg) . With the normal aging process, sinus walls become atrophic and probably dehiscent, augmenting the risk of OF. In young individuals, a congenital defect, a polypoid lesion, or an inflammatory process can weaken the orbital wall and predispose it to barotraumatic OF . Predisposing factors of reported OFFE cases are upper respiratory tract infections (5 cases including our case) and a history of sinus surgery (1 case), while one patient had no recognizable risk factor . A fracture of the lateral wall of the maxillary sinus was also found with OFFE in one reported case .

Differential diagnosis of eyelid/periorbital swelling ranges from benign, self-limiting dermatoses to malignant tumors and sight-threatening infections. Patients with bilateral eyelid/periorbital swelling may have angioedema, atopic dermatitis, blepharitis, contact dermatitis, rosacea, adverse reaction of medicaments (e.g. imatinib, NSAIDs, bisphosphonates), or some systemic diseases (e.g. myxedema, renal disease, congestive heart failure, superior vena cava syndrome). Unilateral eyelid/periorbital swelling can arise from cellulitis, abscess, insect bites, herpes simplex/zoster infections, dermatomyositis, lupus erythematosus, hordeolum, chalazion, and tumors (e.g. hemangioma, basal cell, sebaceous and trichoblastic carcinomas) . OFFE caused by nose blowing usually occurs unilaterally and rapidly after a forced expiratory effort, with no sign of infection. The diagnosis of OFFE is confirmed by orbital CT . Details on differential diagnosis of eyelid/periorbital swelling were extensively reviewed by other authors .

Most OEms resolve within a few weeks and therefore require no treatment. However, during this period, the patient should avoid blowing the nose, sneezing, vomiting, or performing the Valsalva maneuver . Rarely, the increased INP causes an acute compartment syndrome with optic nerve or retinal artery compromise, which requires prompt diagnosis and management . Forced air onto the impacted extraocular muscle and/or fracture of the lamina papyracea can trigger vagal hyperactivity and subsequent syncope, while the oculocardiac reflex caused by traction on extraocular muscles can precipitate cardiac arrest . Moreover, air may descend and occupy the parapharyngeal/retropharyngeal space, thoracic and abdominal cavities, causing retropharyngeal emphysema, pneumomediastinum, pneumothorax, pneumopericardium, and mediastinitis . In some circumstances, air penetrates the cranium, leading to pneumocephalus .

Owing to the risk of concomitant sinusitis and/or penetration of nasal secretion into the orbital cavity, broad-spectrum antibiotic prophylaxis is recommended. Once ophthalmoplegia and increased intraocular pressure (IOP) are found, high-dose corticosteroid helps prevent ischemia and damage to the optic nerve. Indications of surgical treatment for OFFE are similar to those for OF alone, such as visual impairment, limited eye movement, and entrapment of the orbital soft tissue, necessitating orbital bone reposition and reconstruction with an appropriate material. Expanding or extensive OEm may require lateral canthotomy or cantholysis, orbital decompression with needle aspiration, and bone decompression, or a combination of thereof .

Lateral canthotomy (LC) is essential for retrobulbar hematoma with increased IOP (> 40 mmHg), relative afferent pupillary defect, decreased vision, proptosis, and decreased ocular motility. However, LC can damage the periocular tissue, resulting in ectropion, ptosis (damage to the levator aponeurosis when cut too superiorly), damage to the lacrimal gland or lacrimal artery, globe injury, and cosmetic deformity. An absolute contraindication of LC is open globe injuries (enophthalmos, exposed uvea, or an irregularly shaped pupil) .

Our patient was hospitalized for two days for close observation and antibiotic therapy (Unacid 2 g. t.i.d.). One day later, she complained about vision deterioration of the right eye and problems while seeing colors (right: 0.6 Diopter; left: 0.8 Diopter). An urgent orbital CT was ordered, but no further abnormality was detected. On hospital day 2, visual impairment and diplopia subsided spontaneously. Repair was deemed unnecessary. After discussion with the patient, we decided not to perform any operation. The patient was then discharged home. We advised her to refrain from forceful nose blowing and to use physiologic water for nasal rinsing, followed by nasal decongestant. Oral antibiotic was prescribed until 7 days after injury.

Hunts et al. proposed a staging protocol for recognition and management of orbital emphysema. This patient, with proptosis, loss of vision and increased IOP but without central retinal artery occlusion, had stage III disease. She was followed closely, and by 2 weeks the emphysema, ecchymosis, diplopia and restricted eye movements resolved completely with full resolution as evident on CT. At the time of this writing, she made an uneventful recovery with a return to normal vision for 28 months.