Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Orbital and Neck Emphysema (Secondary to Extensive Nose Blowing)
This patient blew his nose with great force and developed swelling in the right periorbital region, right face, and right neck. He had a history of chronic intranasal cocaine use. He denied recent facial trauma. On exam, he had right preseptal crepitus. He had no signs of infection. He was treated with a course of clindamycin for prophylaxis against infection.
Sneezing and nose blowing can suddenly increase intranasal pressure. Orbital emphysema can result from dehiscence of the lamina papyracea. Predisposing factors include thinning of the sinus wall with age and chronic sinus inflammation leading to localized osteomalacia. In this case, chronic cocaine use may have lead to local ischemia and sinonasal wall thinning.
Complications of orbital emphysema include ischemic optic neuritis and central retinal artery occlusion. Trapped intraocular gas can by drained underwater with a 24 gauge needle or removed by lateral canthotomy. Orbital emphysema can be treated with cold packs, oral antibiotics, and nasal spray decongestants.
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