Medial Wall Orbital Fracture and Orbital Emphysema

A previously healthy 11-year-old boy presented to the emergency department with acute right eye pain and swelling. He had been elbowed in the eye 3 days prior but had noted only minimal swelling at the time. Earlier on the day of presentation, he had sneezed and had experienced immediate pain and significant swelling to the lower eyelid. He complained of mild pain to the right eye and a subjective feeling of limited upward gaze, but he reported no changes in vision. He denied headache, vomiting, recent illness, or fever. The patient had no significant medical history and did not wear glasses or contact lenses.

Upon presentation to the ED, infraorbital swelling was obvious, with erythema and a linear bruising pattern at the infraorbital rim (A). Extraocular muscles were intact, except for minimal asymmetry on upward gaze, with the patient reporting a subjective upward gaze limitation (B).

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There was pain to palpation over the medial right border of the nasal bridge, but no crepitus or palpable bony step-off. No proptosis, enophthalmos, or subconjunctival hemorrhage was present. His pupils were equal, round, and reactive to light, and his vision was 20/20 bilaterally. The rest of the examination findings were normal.

Because of a clinical concern for an orbital fracture with extraocular muscle entrapment, an orbital computed tomography (CT) scan without contrast was performed. The CT images showed right-sided postseptal soft-tissue gas (emphysema) related to the acute fracture of the right lamina papyracea, without muscle entrapment (C and D).

Clinicians should maintain a high index of suspicion for orbital wall fractures in patients in whom there is any indication of high-force trauma to the eye, crepitus or step-off, vision changes, or signs of muscle entrapment. Orbital CT imaging should be considered to localize the fracture and identify any associated injuries. Isolated medial wall fractures occur in 10% to 30% of cases of orbital trauma.^1-3

With any nasoethmoid or lamina papyracea fractures, the medial rectus muscle may be come incarcerated, which can lead to restriction of horizontal mobility of the affected eye.^4,5 One study of 76 patients showed that the incidence of eye movement limitation in medial wall fractures was 12.5% and diplopia was 25%.⁶ Furthermore, orbital emphysema can occur after forceful injection of air into orbital soft tissue spaces, as was seen in our case after a sneeze. This usually is caused by trauma, and the presence of orbital emphysema in the absence of an apparent fracture suggests an occult fracture of the orbit.⁴ Complications of orbital emphysema can include proptosis, loss of vision, increased intraocular pressure, and decreased eye movement.¹

The management of orbital fractures with orbital emphysema depends largely on the clinical presentation. For orbital emphysema, emergent decompression is necessary if there is any suspicion of orbital compartment syndrome; otherwise, it will resolve on its own as air is absorbed.⁵ Surgical repair of fractures within 2 weeks is indicated in cases featuring diplopia with entrapment, large fractures, and enophthalmos.⁵ Antibiotic treatment remains controversial.^3,7

Our patient had a medial wall orbital fracture and orbital emphysema without muscle entrapment. While entrapment is the most common reason for decreased eye mobility, other causes have been reported in the literature, including traumatic hemorrhage and swelling of the orbital fat.⁸ Our patient’s subjective feeling of decreased movement likely was a result of infraorbital swelling and the orbital emphysema.

References:

1.Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema: staging and acute management. Ophthalmology. 1994;101(5)960-966.

2.Lee HJ, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol. 2004;10(4):168-172.

3.Koltai PJ, Foster JA, Papay FC, Castro E. Pediatric orbital fractures. In: Holck DEE, Ng JD, eds. Evaluation and Treatment of Orbital Fractures: A Multidisciplinary Approach. Philadelphia, PA: Elsevier Saunders; 2006:209-224.

4.Segrest DR, Dortzbach RK. Medial orbital wall fractures: complications and management. Ophthal Plast Reconstr Surg. 1989;5(2):75-80.

5.Gauguet J-M, Lindquist PA, Shaffer K. Orbital emphysema following ocular trauma and sneezing. Radiol Case Rep. 2008;3(1):124-129. doi:10.2484/rcr.v3i1.124.

6.Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg. 1999;103(7):1839-1849.

7.Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg. 2000;38(5):496-504.

8.Putterman AM. Management of orbital floor blowout fractures. Adv Ophthalmic Plast Reconstr Surg. 1987;6:281-285.