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SRM University Journal of Dental Sciences

Volume 2, Issue 2, April - June 2011

Case Report

Post traumatic pneumo orbitus - Report of two cases

Mohanavalli S, Senthil Murugan M, Kamal Kannadasan, Nikhil Govindan
Department of Oral and Maxillofacial Surgery, SRM Dental College, Ramapuram, Chennai
Address for correspondence
Dr Mohanavalli S
Department of Oral and Maxillofacial Surgery,
SRM Dental College
Ramapuram, Chennai - 600 089

Abstract
Pneumo orbitus results from fracture of the lamina papyraceae
or maxillary roof allowing passage of air from the sinuses to the
orbit. Most of the cases present with history of trauma, whereas
in some patients spontaneous pneumo orbitus follows violent
nose blowing or sneezing. Though this condition is generally a
non-emergency situation, for which mere supportive treatment
is needed, in certain emergency states of pneumo orbitus, early
diagnosis and immediate treatment is required to prevent visual
loss.
Keywords: Subcutaneous emphysema, pneumo orbitus,
orbital emphysema, traumatic emphysema

Introduction

Case Report

Paranasal air sinuses are the main sources of air diffusion

within facial tissues which may appear as emphysema
secondary to fronto-naso-orbito-ethmoidal and maxillofacial
injuries.1 Fracture through the ethmoidal sinus wall with
injury to the lining mucosa allows the air to escape into the
facial spaces more frequently. Whereas, the air that enters into
the periorbitum from maxillary sinus is less frequent.2
Periorbital mucosa allows the air inflation owing to its loose
areolar tissue. This air may enter into the retroseptal or intra
orbital region that creates a 'Pneumogram' (air outlines the
globe of the eye and its ligamentus attachment in a remarkable
fashion) image in the conventional radiograph3. Intra orbital
air is usually seen superiorly but can occur anywhere within
the globe. Large amount of air can collect in the pre-septal
space, on occasion, behind the globe which is innocuous and
self-limiting. Few cases of tension pneumo orbitus, which
resemble retrobulbar haemorrhage, with chemosis lead to
disturbed visual acuity.5 It can also occur as a delayed
manifestation of an orbito-antral fistula, particularly in
patients who have undergone treatment for blow-out
fractures. Patients experience swelling and crepitus following
nose blowing. Most of the intra orbital air resorbs within a few
days to a week. However few cases of this nature warrant a
more cautious attitude.7

Case 1
A 29yr old male patient reported with a complaint of pain and
swelling around the right eye for the past 2 days. He gave a
history of accidental injury to the eye with an object (metal
ring) 4 days back with pain and mild swelling around the eye.
The patient also reported that the swelling increased in size
when he would forcefully expire air. He was able to feel a
crackling sensation when he pressed his finger on the
swelling and a sensation of fullness of the face with difficulty
in closing of the eyelids on the right side. On examination, a
well marked swelling in the right side of the face,
circumorbital edema, ecchymosis was seen (Figure 1). On
palpation (rolling of two fingers over the swelling produced a
characteristic crackling sensation) crepitation, tenderness
was present. Crepitation was also noted by auscultation with a
stethoscope. This is almost pathognomonic for subcutaneous
air emphysema. No complaint of difficulty in ocular
movements, visual disturbance, vision loss and diplopia was
reported.

158

Radiographic PNS reports revealed multilocular

radiolucencies suggesting of subcutaneous emphysema in the
floor of the right orbit (intra orbital air) and fractured medial
wall of the orbit. CT scan reports revealed a fracture at the

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Post traumatic Pneumo orbitus - Report of 2 cases

Mohanavalli S et al

inferiomedial wall of the right orbit with herniation of intra

orbital contents into the right maxillary antrum (Figure 2) and
air pockets in the retrobulbar region of the right orbit and in
supra-orbital soft tissues (Figure 3). It was therefore
diagnosed as right pneumo-orbitism.
Ophthalmologist's opinion was also obtained to rule out
retrobulbar haemorrhage, tension pneumo orbitus and visual
acuity.
The patient was put on antibiotic coverage (Amoxicillin
500mg/tid/ 5days) along with nasal decongestant (4 times a
day for 5 days) and cough suppressants. The patient was kept
under observation and instructed not to blow his nose8.
Follow up was done once weekly for 2 month.

Figure 3: CT image shows retrobulbar air emphysema,

Figure 1: Immediate post traumatic emphysema on right

side of the face

Figure 4: Two week after post traumatic view

Figure 2: CT image shows fracture at infero medial wall of

orbit with herniation of orbital fat

Figure 5: Two weeks review complete resorbtion of air

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Post traumatic Pneumo orbitus - Report of 2 cases

Mohanavalli S et al

Case 2
A 25 year old male patient reported to our department with the
complaint of swelling over the right eye for the past 3 days. He
gave a history of a bike accident 4 days back with loss of
consciousness for 1 hour with no history of vomiting. He had
a lacerated wound in the right eyebrow region for which
sutures were placed in a private hospital and first aid was
given. He was then referred to our hospital. On examination,
the patient was conscious and well oriented. He presented
with periorbital swelling and subconjuctival ecchymosis
(Figure 6). On palpation, tenderness and crepitus was noted.
There was no difficulty in eye movements. But complete
opening of the eye was hindered due to swelling. The vision
was normal.
CT reports revealed a fracture in the right frontal bone with
mild displacement of the outer table in the frontal sinus
(Figure 7). PNS view radiograph was also taken which
showed fracture at frontal bone with the involvement of
frontal sinus (Figure 8). The case was diagnosed as pneumo
orbitus in the right eye with the air in the preseptal space.
Ophthalmologist opinion was taken to rule out visual acuity
and tension pneumo orbitus. The patient was advised open
reduction for frontal bone fracture but he was not willing to
undergo any surgical procedure. He was treated
conservatively. Antibiotics (Amoxicillin 500mg/tid/ 5days),
nasal decongestant (nasal drops 4 times a day for 5 days) and
antitussive were prescribed. The patient was kept under
observation and instructed not blow his nose8. Follow up was
done once a week for 2 month and at the end of first month the
swelling had completely subsided and did not show any
recurrence or any deformity in the vision.

Figure 7: CT image shows preseptal air emphysema

Figure 8: PNS shows fracture at frontal bone with the

involvement of frontal sinus

Figure 6: Immediate post traumatic emphysema on right of

the face
Figure 9: Two weeks review complete resorbtion of air

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Post traumatic Pneumo orbitus - Report of 2 cases

Discussion
Subcutaneous emphysema occurs after a short period
following trauma, when air enters the facial tissues. Post
traumatic subcutaneous emphysema appears in the
periorbital subcutaneous tissues rather than the orbit itself.4
Brasileiro et al3 reported that medial orbital fractures
involving the ethmoidal sinuses were the main reason for
periorbital emphysema in zygomatico-orbital maxillary
complex fractures or midfacial fractures. Hunts and co
workers classified orbital emphysema into four groups7.
Stage I: No proptosis/dystopia, no loss of vision, no increase
in intra ocular pressure, no central retinal artery occlusion.
Stage II: As in stage I, except proptosis/ dystopia is present.
Stage III: Proptosis/dystopia present, loss of vision, possible
rise in intraocular pressure. No central retinal artery
occlusion. Stage IV: All of the above are positive including
central retinal artery occlusion .They suggest that Stage
1patients are common and are easily recognised by
radiography and no special imaging is required. Stage 2
patients require CT to rule out other intra orbital lesions.
Stage III patients require emergency CT if available, to locate
air for needle aspiration. Stage IV patients require rapid
orbital decompression and this should not be delayed by
acquiring further imaging.

Mohanavalli S et al

reviewed once weekly and after two weeks emphysema was

completely resolved without any complications (Figure 4, 5).
The second patient was advised open reduction for the frontal
bone fracture but he was unwilling to undergo any surgical
procedure, he was also kept under observation and treated
with conservative methods. He reported after two weeks
without any other complications (Figure 9). Most of the
authors suggested that intra orbital air resorbs within few days
to a week.7 Generally, this condition is benign and usually
asymptomatic, no specific treatment is required. But in some
cases the pneumo orbitus may enlarge causing occlusion of
retinal artery by increasing the intra-orbital pressure thus
leading to proptosis and loss of vision.4 The onset of blindness
can be extremely rapid and although these conditions are
identifiable on CT, as a general rule no imaging should take
place as this merely prolongs the time to treatment and risks
the blindness becoming permanent. In such cases, a more
cautious attitude is required with either immediate needle
aspiration or lateral cantholysis, and canthotomy under local
anaesthesia in the emergency room.

References
1.
2.

In the first patient emphysema developed 2 days after trauma

and increased in size during expiration and forceful nose
blowing. There was no proptosis, no vision loss, no restriction
in the ocular movement but periorbital ecchymosis and
oedema on the right side was present. On palpation,
pathognomic crepitation and crackling was present which
confirmed subcutaneous emphysema. CT reports also
confirmed right pneumo-orbitism with a fracture at the
infero-medial wall of right orbit with herniation of intra
orbital contents into the right maxillary antrum and air
pockets in the retrobulbar region. The Second patient
presented with periorbital swelling, subconjuctival
ecchymosis, tenderness and crepitus. CT reports confirmed
pneumo orbitus with preseptal air due to the fracture in the
right frontal bone with the frontal sinus involvement. For both
the patients, Ophthalmologist's opinion was taken to rule out
visual acuity and tension pneumo orbitus, no emergency
treatment was required for both patients.
For the first patient, even though he had orbital floor fracture
with herniation of orbital fat, he was treated conservatively
and instructed to not to blow his nose vigorously. He was

Streamdent, 2(2), 2011

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