Tension pneumo orbitus e A case report and review of literature
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Transcript of Tension pneumo orbitus e A case report and review of literature
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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: [email protected]/$ 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
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