Orbital and Subcutaneous Emphysema Mimicking Cellulitis after Nose Blowing

Guest Editor: H. Ralph Schumacher, Jr, MD

University of Pennsylvania School of Medicine, Philadelphia

Resident

Resident

Program Director

St. Joseph Hospital

Orbital and subcutaneous emphysema after trauma has been well documented, but its development in the absence of a clear history of trauma is rare. We report a case of unilateral orbital emphysema, which occurred after nose blowing and mimicked orbital cellulitis as a result of gas-producing organisms. A few cases of bilateral orbital emphysema after harmless nose blowing have also been reported in the literature.

Case Presentation

A 51-year-old black man with a history of diabetes and paranoid schizophrenia was brought to the emergency department from a nursing home with complaints of right-sided periorbital swelling and protrusion of the eye that began 24 hours earlier. He denied any history of trauma or upper respiratory tract infection, difficulty with vision, fever, or chills. Physical examination showed he was afebrile; the right eye was proptotic, with severe chemosis of the conjuctiva (Figure 1). His eye movements were severely restricted on the right side, but his vision was well preserved. No warmth or erythema was noted, but palpable crepitus was evident over the temporal and maxillary areas of his face.

Computed tomography (CT) of the orbits revealed air in the right orbital cavity, with subcutaneous emphysema in the right temporal and infratemporal areas (Figure 2). The left orbit and its contents were normal. Other findings included mucosal thickening of the ethmoid air cells. White blood cell count was within normal limits. Because cellulitis of the orbit by gas-producing organisms was suspected, broad-spectrum antibiotics were prescribed, and the patient was admitted to the general medical service. Ophthalmology, otolaryngology, and infectious diseases consults were obtained.

Closer review of the CT films with the radiologists revealed a defect in the lamina papyracea bilaterally (Figure 3). On further questioning, the patient admitted he had forcefully blown his nose frequently on the previous day, which led to the diagnosis of orbital emphysema caused by nose blowing.

His antibiotics were continued, and compresses were applied to the right eye. Blood cultures were negative, and the patient improved dramatically by the next day. Repeat CT showed resorption of the air in the orbit. He was discharged with a prescription for oral antibiotics and advised not to blow his nose. The emphysema resolved slowly over a couple of weeks.

Discussion

Orbital emphysema is usually a benign, transient event. Rarely, an intraorbital air mass can compromise vision by occluding the central retinal artery. Because of the potential for severe vision loss, early diagnosis and immediate management are necessary.

Orbital emphysema is usually seen in association with medial orbital wall fractures after blunt trauma. Less frequently, orbital emphysema has occurred spontaneously after violent sneezing, coughing, or nose blowing1-3; secondary to compressed-air injuries; and in association with certain tumors or bacterial infections of the orbit. Diagnosis can be made based on the history and physical examination and is supported by CT scanning.

Management of infectious causes of orbital emphysema usually requires urgent surgical and medical interventions.4 Management of orbital emphysema associated with fractures or trauma includes prophylactic oral antibiotics, decongestants, and advising the patient against nose blowing. If proptosis and diplopia are present but no vision loss is involved, CT imaging may help rule out other intraorbital pathology.

Treatment is observation unless the patient has significant discomfort, in which case orbital decompression using a needle with a syringe is necessary. This procedure is usually done by an ophthalmologist.

If vision loss occurs, urgent orbital CT is indicated to localize the air mass. Immediate decompression with a needle and a syringe is also necessary. Ischemic damage to the optic nerve can be prevented with the administration of intravenous steroids. If the vision loss is severe (absence of light perception), surgical decompression is indicated.5

J Laryngol

Otol.

1. Dunn C. Surgical emphysema following nose blowing. 2003;117:141-142.

J Laryngol Otol.

2. Mohan B, Singh KP. Bilateral subcutaneous emphysema of the orbits following nose blowing. 2001;115:319-320.

N Engl J Med

3. Kaplan K, Winchell GD. Orbital emphysema from nose blowing [letter]. . 1968;278:1234.

Br J Radiol

4. Lloyd GA. Orbital emphysema. . 1966;39:933-938.

Ophthalmology.

5. Hunts JH. Orbital emphysema. Staging and acute management. 1994;101:960-966.

Commentary

Jason G. Newman, MD

Assistant Professor

Gregory S. Weinstein, MD

Professor and Vice Chairman

Director, Division of Head and Neck Surgery

Department of Otorhinolaryngology, Head and Neck Surgery

University of Pennsylvania, Philadelphia

As the authors suggest, orbital emphysema is most commonly caused by trauma, and the air usually localizes at or near the fracture site. Other causes of this relatively rare phenomenon include infection, iatrogenic injury (sinus surgery), and pulmonary barotrauma. Spontaneous orbital emphysema caused by sneezing or aggressive nose blowing (as in this case) has been reported but is quite unusual.

The diagnosis of this condition can be made clinically or with imaging studies. Historically, plain radiographs were the diagnostic tool of choice. However, CT scanning is currently the most accurate means of diagnosis and will also localize the air bolus in the event of planned surgical decompression.

When evaluating a patient with orbital emphysema, it is necessary to ask about any recent or previous surgery or trauma to the area, current signs or symptoms of infection, or pain over the area. Physical examination should focus on visual acuity, range of motion, and the presence of pain with movement.

Treatment is based on the presumed etiology. In most instances, observation is all that is required. The air will resorb, and no intervention will be necessary. Many physicians, however, will tend to prescribe prophylactic antibiotics, because of the concern that the mucosal tear responsible for the air will also seed the area with sinonasal bacteria. In cases of infectious etiology, the source of the infection should be identified and treated appropriately. Ophthalmology, otolaryngology, or infectious diseases consultation may be appropriate.

Depending on the severity of the injury, surgical intervention or antibiotics may be considered. In rare cases, patients have been reported to develop retinal artery compression or compressive optic neuropathy.1 Should the patient demonstrate any evidence of visual compromise or decreased range of extraorbital motion, surgical consultation should be obtained. Needle or operative decompression of the air will most likely be necessary.

As in this case, unexpected causes of this phenomenon do occur, and the clinician needs to obtain a thorough and accurate history when no obvious cause of orbital emphysema exists.

Mayo Clin Proc.

1. Zimmer-Galler IE, Bartley GB. Orbital emphysema: case reports and review of the literature. 1994;69:115-121.