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Case Report

Tension pneumo orbitus e A case reportand review of literature

Dilip S. Kiyawat

Hon. Neurosurgeon, Jehangir Hospital, Pune, India

a r t i c l e i n f o

Article history:

Received 3 August 2013

Accepted 7 August 2013

Available online 7 September 2013

Keywords:

Pneumo orbitus

Tension

Orbital emphysema

E-mail address: dilipkiyawat@gmail.com.0976-0016/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.apme.2013.08.003

a b s t r a c t

Communication between paranasal sinuses and orbital wall can occur after trauma,

infection or surgery. In such cases repeated increase in intranasal pressure can lead to one

way entry into the orbit due to ball valve mechanism. This leads to tension pneumo

orbitus, a condition, which can cause rapid deterioration of vision, diplopia and proptosis.

Immediate treatment in the form of, either needle aspiration or repair of medial orbital

wall is recommended. In this case report visual loss and proptosis recovered spontane-

ously in 8 days. The literature has been reviewed.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction 2. Case report

Air in the orbital cavity can be seen in head injuries with blow

out fractures of the orbit. Fracture of paranasal air sinuses

outlining the orbit leads to air entering the orbit. This condi-

tion has been described by many terminologies, such as,

orbital emphysema, pneumatocele of orbit, orbital pneumo-

cele and pneumo orbitus. It is usually a benign and self

limiting condition. It is also seen as an incidental finding in

post head injury CT scans. Although there is history of ante-

cedent trauma, spontaneous pneumo orbitus can occur in

cases of sinusitis and erosion of bone around the orbit.

Though a benign course in most cases, it may become an

emergency due to rapid deterioration of vision due to

increased intra orbital pressure, which may necessitate sur-

gical intervention. This case report describes a case of prop-

tosis and visual loss following a blunt injury on head. The

patient showed spontaneous recovery. The literature on

orbital pneumocele has been reviewed.

2013, Indraprastha Medic

A 35 years old male labourer sustained head injury to his left

supra orbital region by a concrete slab with no immediate

consequences. A few days later, he developed proptosis of the

left eye, redness of conjunctiva and rapid deterioration of

vision in that eye. On examination, hewas fully conscious and

positive findings were noted in left eye only. There was

proptosis with slight downward deviation, redness of con-

junctiva and marked diminish in vision of only perception of

light. Swelling of left upper lid and crepitus also noted. Ocular

movements were restricted in all the directions.

CT scan showed air in the orbital cavity, fracture of medial

orbital wall, proptosis and air in the upper eyelid (Fig. 1).

Due to deteriorating vision he was advised surgical inter-

vention in the form of aspiration of air, which he declined and

went home. He returned 8 days later, when examination

showed regression in proptosis and full improvement of

vision, ocular movements and crepitus.

al Corporation Ltd. All rights reserved.

Fig. 1 e Tension pneumo orbitus showing left proptosis and fracture site arrow(A) and downward deviation of left eyeball (B).

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 3 7e2 3 9238

Follow up CT scan showed, (Fig. 2 A and B) there was no air

in the orbital cavity, proptosis had regressed and some air was

seen in the upper eyelid.

3. Discussion and review of literature

Presence of air inside the orbit in orbital fractures is seen in as

much as 50% of cases.1 This condition has been described by

many terminologies, such as, orbital emphysema, pneuma-

tocele of orbit, orbital pneumocele, and pneumo-orbitus. In

majority of cases this condition runs a benign course, the intra

orbital air gets absorbed without any consequences. However,

in certain cases the intra orbital pressure increases if the

fracture produces a ball-valve effect where, due to each event

in increase in intranasal pressure, air enters and gets trapped

in the orbit, thus producing Tension Pneumo Orbitus.

Fig. 2 e CT scan 8 days later shows very little air arou

Consequently the patient can develop proptosis, dystopia,

visual loss, ophthalmoplegia, conjunctival haemorrhage, lid

oedema and crepitus in the lid.

Orbital emphysema is commonly associated with fracture

of orbit, the most common fracture site is the medial wall of

the orbit, the lamina papyracea2e5 but rarely the roof, due to

fracture of enlarge frontal sinus or floor, due to fracture of

maxilla could be the cause of air entry.4,6 Communication of

orbit with paranasal sinuses due to infection, tumour or sur-

gery can also lead to orbital emphysema.5,7,8

Hunts et al have classified orbital emphysema in four

stages. Stage 1 e Only presence of air with no increase in intra

ocular tension or ocular complications, Stage 2- as in stage

1except presence of proptosis and dystopia, stage 3e proptosis,

dystopia, loss of vision and possible rise in intra ocular pres-

sure, no central retinal artery occlusion, stage 4 e All above

are present along with central retinal artery occlusion.2

nd the eyeball axial view A, coronal view B and C.

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 3 7e2 3 9 239

Orbital emphysema is a medical emergency and may

require immediate surgical intervention. Most of these cases

are treated by needle aspiration, where a saline filled syringe

(without piston) is attached to the needle to monitor the air

escaping.1,6,8,9

Zimmer-Galle10 described seven cases and reviewed 78

cases from literature since 1900. He noted trauma as the most

frequent cause of orbital emphysema; however, orbital

emphysema also may occur spontaneously or as a complica-

tion of pulmonary barotraumas, infection, and operation. He

concluded that orbital emphysema is an incidental finding

and resolves with time. The present case reported here,

although had developed visual loss, also showed spontaneous

recovery after 8 days.

The second most common cause of orbital emphysema is

infections in the paranasal sinuses leading to erosion of

sinus wall.5,7,8 Intra orbital air has been reported by Boulos et

al in a rare case of pneomocele (frontal mucosal sac herni-

ating into the orbit) due to frontal sinusitis, which was

treated by endoscopic sinusotomy and excision of mucosal

sac.7 Erosion of frontal sinus leading to pneumatocele was

treated by Purohit at al by endoscopic sinusotomy and

correction of outlet check valve with improvement of prop-

tosis and diplopia.5 Muthiah described a similar case of

proptosis and diplopia caused by orbital emphysema due to

frontal pneumocele.11 Spontaneous orbital emphysema has

also been described due to repeated and forceful nose

blowing or sneezing. These acts can cause fracture of

ethmoid wall in cases of infection or previous intranasal

surgery. Many authors have emphasized the importance of

preventing nose blowing following orbital fracture or

surgery.2,8,12e14

Fleishman described two cases of orbital emphysema with

visual loss which were successfully treated by lateral can-

thotomy and cantholysis.15 A number of authors have advo-

cated surgical repair of themedial orbital wall by open surgery

or with endoscope.9,16,17

Patients with orbital fracture or recent operation on orbit

run increased risk of developing orbital pneumocele due to

sudden atmospheric changes such as during air travel. Mon-

aghan reported a similar case of orbital emphysema that

required early surgical intervention.18 Patients who recently

has orbital fracture of surgery around the nose or orbit are

advised against air travel.

4. Conclusion

Pneumo orbitus is a common finding on CT scan in cases of

orbital and ethmoid fractures. Rarely, tension pneumo orbitus

develops due to one way valve mechanism and leads to

proptosis and visual loss. Emergency intervention to relieve

the trapped air has been advocated. However, spontaneous

regression of air reported in the literature and in the present

case even with vision loss, needs review of strategy as regards

surgical intervention.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Dobler AA, Nathenson AL, Cameron JD, Carpel ET, Janda AM,Pederson JE. A case of orbital emphysema as an ocularemergency. Retina. 1993;13(2):166e168.

2. Gloaguen Y, Cochard-Marianowski C, Potard G, Rogez F,Meriot P, Cochener B. Post-traumatic orbital emphysema: acase report. J Fr Ophtalmol. 2006 Oct;29(8):e18 [Article in French].

3. Jordan DR, White Jr GL, Anderson RL, Thiese SM. Orbitalemphysema: a potentially blinding complication followingorbital fractures. Ann Emerg Med. 1988 Aug;17(8):853e855.

4. Mahanavalli S, Senthil Murugan M, Kamal Kannadesan,Nikhil Govindan. SRM University J of Dental Society. AprileJune2011;2(2):158e161.

5. Purohit SS, Levine MR. Pneumatocele of the orbit. OphthalPlast Reconstr Surg. 1999 Mar;15(2):126e128.

6. Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbitalemphysema. Staging and acute management. Ophthalmology.1994 May;101(5):960e966.

7. Boulos PR, Bernardino CR, Rubin PA. Pneumocelee a rare causeof air in the orbit. Am J Ophthalmol. 2004 Jul;138(1):168e169.

8. Garcıa-Medina JJ, Garcıa-Medina M, Pinazo-Duran MD. Severeorbitopalpebral emphysema after nose blowing requiringemergency decompression. Eur J Ophthalmol. 2006MareApr;16(2):339e342.

9. Benharbit M, Karim A, Lazreq M, Mohcine Z. Emergencytreatment of post-traumatic orbital emphysema: a case report.J Fr Ophtalmol. 2003 Nov;26(9):957e959 [Article in French].

10. Zimmer-Galler IE, Bartley GB. Orbital emphysema: casereports and review of the literature. Mayo Clin Proc. 1994Feb;69(2):115e121.

11. Muthiah MN, Day AC, Singh RP, Malik N, Adams ME, Olver JM.Frontal sinus pneumatocele: a rare cause of orbitalemphysema. Clin Experiment Ophthalmol. 2007Nov;35(8):772e773.

12. Gonzalez F, Cal V, Elhendi W. Orbital emphysema aftersneezing. Ophthal Plast Reconstr Surg. 2005 Jul;21(4):309e311.

13. Harmer SG, Ethunandan M, Zaki GA, Brennan PA. Suddentransient complete loss of vision caused by nose blowingafter a fracture of the orbital floor. Br J Oral Maxillofac Surg.2007 Mar;45(2):154e155.

14. Taguchi Y, Sakakibara Y, Uchida K, Kishi H. Orbitalemphysema following nose blowing as a sequel of asnowboard related head injury. Br J Sports Med. 2004Oct;38(5):E28.

15. Fleishman JA, Beck RW, Hoffman RO. Orbital emphysema asan, ophthalmologic emergency. Ophthalmology. 1984Nov;91(11):1389e1391.

16. Akif Bayar M, Fatih Kokes, Cevdet Gokcek, et al. Posttraumatic tension pneumo-orbitus. Turkish Neurosurg.1995;5:34e35.

17. Isherwood Grant, Grubber Elizabeth, Andrew Scott,Ahmed Messahel. Emergency management of post traumatictension pneumo-orbit. FMJS. 2013;3(1).

18. Monaghan AM, Millar BG. Orbital emphysema during airtravel: a case report. J Craniomaxillofac Surg. 2002Dec;30(6):367e368.

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