Posttraumatic orbital emphysema: incidence, topographic classification and possible pathophysiologic mechanisms. A retrospective study of 137 patients

doi:10.1016/j.oooo.2012.10.021

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Volume 115, Issue 6, June 2013, Pages 737-742

https://doi.org/10.1016/j.oooo.2012.10.021 Get rights and content

Objective

The aim of this study was to retrospectively evaluate the incidence of posttraumatic orbital emphysema (OE) and to propose a radiologic topographic classification as well as a possible pathophysiologic model.

Study Design

Orbital fine-cut (1 mm) computerized tomographic scan slices from 137 patients were used to assess the fracture's type, the presence and position of OE, and periorbital tissue herniation. The OE was categorized into the following 5 compartments: subcutaneous periorbital, peribulbar, retrobulbar extra- and intraconal, and pterygopalatine fossa.

Results

The incidence of OE was 61%. OE was more frequently associated with isolated medial wall (78%; P < .001) and combined medial wall/orbital floor (82%; P < .01) fractures. Palpable isolated subcutaneous eyelid emphysema was not related to fracture's type (P = .85).

Conclusions

OE suggested medial wall fractures alone or combined with orbital floor fractures. Pathophysiologically, according to the Poiseuille law, the difference in length between the ethmoid and sinusal infundibulii could explain the increased incidence of OE when the medial wall is involved.

Section snippets

Materials and Methods

Patients were selected from a database of facial trauma at the Hôpitaux Universitaires de Genève, Switzerland, over a 3-year period from 2008 to 2011. The procedure followed in this retrospective study was in accordance with the Helsinki Declaration of 1975, as revised in 2000, and was approved by our local Ethical Board. Only patients with pure orbital fractures (not associated with concomitant midfacial fractures) and available fine-cut CT scans (1 mm) were included. Age, sex, mechanism of

Results

This retrospective study included 137 patients, with a mean age of 43.6 (SD 23.0) years. Sample characteristics are summarized in Table I. All patients presenting OE received 625 mg of amoxicillin and clavulanic acid prophylactically 3 times a day for 5 days. None of the patients presented posttraumatic orbital infection.

The presence of OE was seen in 84 patients (61%), and palpebral subcutaneous crepitation was recorded in 26 patients (19%).

The presence of OE was proportionally lower when

Discussion

The incidence of OE associated with orbital fractures found in this study is the highest reported in the literature. The most plausible explanation is the use of fine-cut CT scan slices, which allowed for the detection of millimetric bubbles of air. Our selection of patients presenting exclusively pure orbital fractures might also explain these higher figures.

Larger retrospective series have reported on general complications following facial fractures, therefore the incidence, treatment and

References (25)

J.H. Hunts et al.
Orbital emphysemaStaging and acute management
Ophthalmology
(1994)
B.B. Rahmel et al.
Comminuted orbital blowout fracture after vigorous nose blowing that required repair
Br J Oral Maxillofac Surg
(2010)
B.F. Brasileiro et al.
Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study
J Oral Maxillofac Surg
(2005)
S.J. Key et al.
Orbital emphysema—the need for surgical intervention
J Craniomaxillofac Surg
(2008)
T.C. Lu et al.
Delayed orbital emphysema as the manifestation of isolated medial orbital wall fracture
J Emerg Med
(2006)
F.P. Nolasco et al.
Medial orbital wall fractures: classification and clinical profile
Otolaryngol Head Neck Surg
(1995)
I.H. Park et al.
Volumetric study in the development of paranasal sinuses by CT imaging in Asian: a pilot study
Int J Pediatr Otorhinolaryngol
(2010)
H. Shinohara et al.
Implication of differences in the incidence of orbital emphysema in ethmoidal and maxillary sinus fractures
Ann Plast Surg
(2004)
H.J. Lee et al.
CT of orbital trauma
Emerg Radiol
(2004)
J.S. Burm et al.
Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture
Plast Reconstr Surg
(1999)

A. Rubinstein et al.

Orbital emphysema leading to blindness following routine functional endoscopic sinus surgery

Arch Ophthalmol

(2005)

F. Di Lella et al.

Orbital and infratemporal fossa emphysema following nose blowing

Clin Otolaryngol

(2008)

Cited by (13)

Radiological Evaluation of the Craniofacial Skeleton
2019, Facial Trauma Surgery: From Primary Repair to Reconstruction
This chapter covers the history and role of radiography, computed tomography (CT), and magnetic resonance imaging (MRI) in the evaluation of the craniofacial skeleton in the setting of blunt and penetrating trauma. The basic craniofacial anatomy is reviewed in all imaging modalities, including a video demonstrating a systematic review of a craniofacial CT. Both common and uncommon craniofacial injuries as well as their potential complications are discussed. The advantages and disadvantages of each imaging modality in both the pre- and postoperative period are also discussed, along with the effective dose of ionizing radiation.
Orbital apex disorders: A case series
2016, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The incidence of retrobulbar hemorrhage resulting in orbital compression ranges from 0.45%37 to 3.6%,38 with most cases associated with fractures of the orbit or zygomaticomaxillary complex. Orbital emphysema is typically a benign condition associated with 50%39 to 60%40 of orbital fractures. In rare cases, an orbital compartment syndrome can occur when the orbital adnexa occludes a traumatic communication between orbit and paranasal sinuses, creating a one-way valve that allows air to enter the orbit but not escape.39,41
Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.
Orbital and Intracranial Emphysema Causing Orbital Compartment Syndrome: A Rare Case Report and Literature Review
2022, Indian Journal of Otolaryngology and Head and Neck Surgery
Traumatic Optic Neuropathy Aggravated by Orbital Emphysema after Orbital Fracture
2022, Journal of Korean Ophthalmological Society
Management of recurrent pneumo-orbit secondary to post traumatic sino-orbital fistula using a navigation-guided customised 3D printed titanium implant: a case report and review of literature
2021, Oral Surgery
Case report: Atraumatic orbital emphysema after bronchoscopy with endobronchial biopsy
2021, Optometry and Vision Science

View all citing articles on Scopus

View full text

Oral and maxillofacial surgeryPosttraumatic orbital emphysema: incidence, topographic classification and possible pathophysiologic mechanisms. A retrospective study of 137 patients

Objective

Study Design

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Ophthalmology

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Craniomaxillofac Surg

J Emerg Med

Otolaryngol Head Neck Surg

Int J Pediatr Otorhinolaryngol

Implication of differences in the incidence of orbital emphysema in ethmoidal and maxillary sinus fractures

Ann Plast Surg

CT of orbital trauma

Emerg Radiol

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture

Plast Reconstr Surg

Orbital emphysema leading to blindness following routine functional endoscopic sinus surgery

Arch Ophthalmol

Orbital and infratemporal fossa emphysema following nose blowing

Clin Otolaryngol

Oral and maxillofacial surgery
Posttraumatic orbital emphysema: incidence, topographic classification and possible pathophysiologic mechanisms. A retrospective study of 137 patients