Case description and discussion:

57-year-old male, no background, admitted in our medical emergency department with sudden-onset back-eye pain and proptosis of the left eye after containing a sneeze. He did not present fever, periorbital redness, eye movement limitation or loss of visual acuity. There was no history of head trauma nor recent surgical interventions. A head computed tomography (CT) revealed intra and extra-conical areas of pneumo-orbit foci in the left eye (Fig. 1,arrow) with a small area of papyraceous lamina dehiscence (Fig. 1,*). The diagnosis of pneumo-orbit was made. He was kept under surveillance and underwent spontaneous resolution after two days.

Pneumo-orbit means the presence of air in the orbital soft tissue space. Most cases follow fracture of an orbital bone, usually after trauma or surgical procedures communicating with paranasal sinus.¹ Infectionwith gas-producing organisms is an important differential diagnosis that should be thought in the presence of fever and elevated white blood cell count.² Rarecases, like the present one, occur spontaneously following nose blowing or sneezing.^3,4 CT scan is the method of choice to identify the presence and extent of the orbital emphysema and to localize the anatomical source of air.⁵ Mostcases are managed conservatively since orbital emphysema should resolve on its own as the air is absorbed. Nevertheless, it is important to recognize this condition because some cases evolve to intra-orbital compartment syndrome, a rare yet sight threatening condition that requires emergent decompression.¹

Figura I

A left eye proptosis is evident. Numerous intra and extra-conical foci of orbital emphysema surrounding the optic nerve (arrow) and in the superior eyelid respectively (arrow). Small area of papyraceous lamina dehiscence is seen (*).

  BIBLIOGRAFIA  

References:

1.Roelofs KA, Starks A, Yoon MK. Orbital Emphysema: A Case Report and Comprehensive Review of the Literature.Ophthalmic Plast Reconstr Surg.2019;35:1-6

2.Kne M, Ra D, Stojkovi M. Acute post-surgical bilateral orbital gas-producing infection—a case report and literature review. Graefes Arch Clin Exp Ophthalmol 2012; 250:1403–6

3.Cruz AA, Eichenberger GC. Epidemiology and management of orbital fractures.Curr Opin Ophthalmol.2004; 15: 416-21

4.Chiu WC,Lih M,Huang TY,Ku WC,Wang W. Spontaneous orbital subcutaneous emphysema after sneezing.Am J Emerg Med.2008; 26: 381.e1-2

5.Khader QA,Abdul-Baqi KJ.Orbital emphysema after a protracted episode of sneezing in a patient with no history of trauma or sinus surgery.Ear Nose Throat J.2010; 89: E12-3