Barotraumatic blowout fracture of the orbit

Orbital Defect and Emphysema After Nose Blowing: A Case Report and Literature Review

A 59-year-old man with a history of obstructive sleep apnea presented to the emergency department for acute swelling of the left upper and lower eyelids after nose blowing. The patient denied prior orbital trauma or surgery and examinations were unremarkable for bony step-offs, lacerations, enophthalmos, proptosis, hypoglobus, or extraocular muscle restriction. Imaging confirmed the diagnosis of left anteromedial orbital floor defect with periorbital emphysema. The orbital floor fracture repair was successfully performed with a MEDPOR implant (Stryker, Kalamazoo, Michigan) to seal the persistent orbital floor defect. A review of the literature revealed common predisposing factors, including forceful nose blowing, remote history of trauma, mucosal inflammation, and smoking.

Biomechanical assessment of orbital fractures using patient-specific models and clinical matching

INTRODUCTION

Orbital wall fractures consider one of the most common fractures in the maxillofacial trauma. These fractures caused by two mechanisms, the buckling mechanism and hydraulic mechanism. This study aims to compare between the two mechanisms in terms of intensity and extension using the finite elements method.

MATERIAL AND METHODS

Three-dimensional model of the skull was generated using computed tomography data of young male patient. Virtual loads were applied on the eyeball and the infra-orbital rim separately. Von Mises stresses were examined in each simulation.

RESULTS

The simulation predicted fractures on the infra-orbital rim and orbital floor when simulating the hydraulic mechanism, and on the orbital floor and mesial wall when simulating the buckling mechanism.

CONCLUSION

Biomechanical studies are essential part in understanding maxillofacial fractures mechanisms. The results confirmed and ascertained what is seen clinically, and explained clearly the two mechanisms of orbital fractures.

Barotraumatic Blow-out Fracture of the Medial Orbital Wall by Nose Blowing

Blow-out fracture is one of the most common facial bone fractures and mainly caused by blunt trauma, whereas barotraumatic causes are relatively rare. In this report, we present the case of a patient with an orbital medial wall blow out fracture caused by nose blowing. This case is unique in that the barotraumatic blow out fracture occurred in a patient without previous known risk factors, except that she had previously been operated on for orbital floor blow-out fracture. It is possible that barotraumatic orbital medial wall fracture occurred due to postoperative changes in the aerodynamics or shock-absorbing capacity of the paranasal sinuses. To prevent barotraumatic trauma in the orbital wall, patients undergoing surgery for orbital fractures should consider avoiding excessive nose blowing not only in the weeks after surgery, but for a sufficient period of time.

Orbital Blowout Fracture and Orbital Emphysema caused by Nose Blowing

A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted.

Orbital Subcutaneous Emphysema in a Child

The authors present a rare case of nontraumatic medial orbital wall fracture in an 11-year-old girl. Fractures of the orbital wall secondary to nose blowing have not been previously described in the pediatric population. The patient reported a history of chronic forceful nose blowing, followed by periorbital swelling after an episode of vigorous nose blowing. Erroneous diagnoses of sinusitis and periorbital cellulitis lead to unnecessary antibiotic treatment. The authors hypothesize that repeated and aggressive nose blowing is analogous to stress fractures, leading to weakening and eventual fracture of the medial orbital wall.

Orbital blowout fracture from nose blowing

Orbital blowout fractures are nearly always caused by acute trauma. Non-traumatic cases of orbital blowout fractures have only been rarely described. In this case study, we discuss an orbital blowout fracture directly caused by nose blowing. The patient developed unilateral eye swelling and orbital emphysema. It is important for the clinician to investigate all suspected orbital blowout fractures with imaging and full ophthalmological examination regardless of a trauma history. Most cases of orbital emphysema resolve spontaneously, however one must always exclude compression of the central retinal artery. This may present as acute loss of vision and/or ophthalmoplegia.

Nontraumatic orbital floor fracture after nose blowing

A 40-year-old woman with no history of trauma or prior surgery presented to the emergency department with headache and left eye pain after nose blowing. Noncontrast maxillofacial computed tomography examination revealed an orbital floor fracture that ultimately required surgical repair. There are nontraumatic causes of orbital blowout fractures, and imaging should be obtained irrespective of trauma history.

A peculiar blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: A case report and review of the literature

Background:

Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event.

Case Report:

A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired.

Conclusions:

Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.

Orbital blowout fracture caused by nose blowing

The occurrence of an orbital blowout fracture caused by nose blowing is an unusual phenomenon. We report a rare case of such a fracture in the bony floor of the orbit of a 30-year-old man. Immediately after strong nose blowing, he experienced left eyelid edema and diplopia. Computed tomography confirmed the presence of a blowout fracture of the inferior wall of the left orbit. His symptoms abated without any surgical treatment. In addition to the facts of this case, we discuss the findings of physiologic studies and human cadaver studies in the context of nose blowing as an etiologic factor in orbital blowout fracture.

Interaction of hydraulic and buckling mechanisms in blowout fractures

The etiology of blowout fractures is generally attributed to 2 mechanisms--increase in the pressure of the orbital contents (the hydraulic mechanism) and direct transmission of impacts on the orbital walls (the buckling mechanism). The present study aims to elucidate whether or not an interaction exists between these 2 mechanisms. We performed a simulation experiment using 10 Computer-Aided-Design skull models. We applied destructive energy to the orbits of the 10 models in 3 different ways. First, to simulate pure hydraulic mechanism, energy was applied solely on the internal walls of the orbit. Second, to simulate pure buckling mechanism, energy was applied solely on the inferior rim of the orbit. Third, to simulate the combined effect of the hydraulic and buckling mechanisms, energy was applied both on the internal wall of the orbit and inferior rim of the orbit. After applying the energy, we calculated the areas of the regions where fracture occurred in the models. Thereafter, we compared the areas among the 3 energy application patterns. When the hydraulic and buckling mechanisms work simultaneously, fracture occurs on wider areas of the orbital walls than when each of these mechanisms works separately. The hydraulic and buckling mechanisms interact, enhancing each other's effect. This information should be taken into consideration when we examine patients in whom blowout fracture is suspected.

Comminuted orbital blowout fracture after vigorous nose blowing that required repair

A fracture of the orbital floor as a result of nose blowing is rare and we know of only three reported cases. We present a 40-year-old man who required repair of a blowout fracture of the orbital floor as a result of vigorous nose blowing. Patients who present with acute periorbital emphysema after nose blowing require careful assessment with potential blowout fractures in mind.

The paranasal sinuses as a protective crumple zone for the orbit

OBJECTIVES/HYPOTHESIS

The purpose of this study is to test the theory that the paranasal sinuses serve a protective function for the central nervous system and special sensory organs.

STUDY DESIGN

Nonrandomized experimental trauma study with fresh human cadavers.

METHODS

Fresh human cadaver heads were obtained and the sinuses on one side underwent endoscopic endonasal sinus surgery and were then filled with radio-opaque bone cement to obliterate them. The contralateral sinuses were not operated upon to allow both for comparison to the experimental side and to serve as an intraspecimen control. The cadavers underwent serial computed tomography (CT) scans. Scans were performed prior to surgery, after surgery, and after unilateral sinus obliteration to obtain baseline CT studies prior to any impact testing. Sequential drops of increasing energy were then performed directing the impacts onto the globes. Initial endpoints were either orbital fractures or ocular injury. Trauma was induced by impacting a weighted rod onto the globes using a guided drop technique. Orbital rim impact was avoided, so that the effect of direct globe trauma could be assessed; fractures were thus induced via the hydraulic mechanism, in which force is transmitted through the globe to the surrounding tissues and orbital walls. After initial injury endpoints were met, additional impact testing was performed on globes, in which fractures occurred with lower drop forces to ensure impact energy equivalence between the control and the experimental sides.

RESULTS

All the experimentally obliterated paranasal sinus orbits tested suffered trauma-induced globe ruptures, and no orbital wall fractures were encountered. On the control sides, no globe ruptures occurred at either an equivalent or higher energy than the energy needed to induce globe ruptures on the experimental side orbits, although orbital floor fractures on the control sides occurred after lower energy impacts in some cases.

CONCLUSIONS

This study demonstrates that the thin orbital floor fractures preferentially, thereby protecting the globe from rupture as a result of the directed trauma. When the sinus crumple zones were eliminated, globe ruptures occurred.

Orbital floor fracture and emphysema after nose blowing

INTRODUCTION

Orbital floor fractures are usually the result of mechanical trauma. Orbital emphysema tends to develop in fractures affecting the paranasal sinuses and walls of the orbit.

CLINICAL CASE

We report the case of a 35-year-old male who suffered an orbital floor fracture with associated orbital emphysema as a result of nose blowing.

DISCUSSION

Only one other similar case has been found in the literature.

An unusual case of medial orbital blowout fracture caused by a headlock

The mechanism of orbital blowout fractures has been proposed in three different theories: the globe-to-wall theory, the hydraulic theory, and the bone conduction theory. However, it is very difficult to identify which mechanism applies in each clinical case from either a history or a physical examination. This report presents an unusual case of an orbital blowout fracture produced by a headlock in a 16-year-old male, which supports the hydraulic theory.

Severe orbitopalpebral emphysema after nose blowing requiring emergency decompression

PURPOSE

Orbital emphysema is a frequent condition associated with medial wall fractures after blunt trauma. It is usually a benign, self-limited phenomenon. The authors are unaware of previous reports of severe orbital emphysema needing emergency decompression with no evidence of any previous significant trauma such as the case presented herein.

METHODS/RESULTS

A 51-year-old woman had painful swelling of the left orbital region that prevented her from opening her eyelids. She complained of a coincident cold with abundant mucous rhinorrhea. She had blown her nose vigorously several times. A computed tomography scan revealed a left proptosis, an extensive orbitopalpebral emphysema, and a blowout fracture of the medial wall of the left orbit. A complete ophthalmic examination was only possible after a needle decompression. No significant ocular damage was observed, so outpatient treatment was provided. Twenty-eight hours later, the swelling had almost disappeared, and the ocular assessment was normal.

CONCLUSIONS

A forceful expiratory effort raising intranasal pressure may cause a medial wall orbital fracture. If the airway hyperpressure episodes are repeated, a severe orbitopalpebral emphysema may develop. Should there be any suspicion of vascular compression, it must be drained to allow the assessment of visual function and theoretically prevent a potentially irreversible ischemic visual loss.

An unusual type of severe barotrauma owing to automobile tire biting in a child

The authors report a rare case of a barotraumatic pneumothorax and pneumomediastinum associated with esophageal perforation and orbital emphysema. A 4-year-old boy presented with sudden respiratory distress after blowout of a defective tire that he bit. Computed tomography scan showed right pneumothorax and bilateral orbital emphysema. A linear rupture has been detected in the cervical esophagus in esophagoscopy. Stamm gastrostomy and tube thoracostomy were performed, and broad-spectrum antibiotics have been introduced. Oral feeding started 23 days after blowout of tire, and the patient was discharged 50 days after injury.

A case of orbital emphysema associated with internal laryngocele

Orbital emphysema (OE) is usually the result of a fracture of lamina papyrecea or maxillary roof allowing air to pass from the sinuses into the orbit. OE without evidence of any significant trauma is a rare occurrence. Thorough literature search revealed that no case of OE due to the rupture of internal laryngocele has been reported. A case is reported here of bilateral orbitopalpebral emphysema associated with internal laryngocele, in the absence of facial skeleton trauma, in a healthy young adult male. It should be kept in mind that laryngocele rupture would be one of the underlying causes of OE or OE would be the presenting symptom of laryngocele rupture.