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      An unexpected complication of sneezing: Blow-out orbital fracture

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          Abstract

          Dear Editor, Blow-out fracture is characterized by a damage to the orbital walls with intact orbital margins and bone fragments displaced outside the orbit. The common mechanism of injury for a orbital fracture is blunt trauma to the orbit or forehead.[1] A 32-years-old man was brought to our emergency department with a swollen condition on his right orbita which began after sneezing. He had horizontal diplopia and crepitus as a sign of periorbital emphysema. Computed tomography scan revealed blow-out fracture on the medial wall of right orbita image, extra conala dipose tissue protruded partially to the superior oblique muscle and free air inside the soft tissue areas [Figures 1 and 2]. Figure 1 Blow-out fracture is seen on the medial wall of right orbita image and free air inside the soft tissue areas Figure 2 On the medial wall of orbita, extraconal adipose tissue protrudes partially to the superior oblique muscle and free air inside the soft tissue areas Clinical symptoms of orbital fracture are diplopia, enophthalmos, or restriction of gaze.[2] Orbital emphysema without impaired vision is not a life-threatening condition and usually resolves spontaneously within 2 weeks. Cases of spontaneous orbital emphysema caused by sneezing, cough, or nose blowing are very rare.

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          Functional outcome after non-surgical management of orbital fractures--the bias of decision-making according to size of defect: critical review of 48 patients.

          The treatment of mild and moderate fractures of the orbital wall is controversial. Apart from clinical signs, the size of the defect is often used to aid the decision about treatment. We hypothesised that variables would be present that had an impact on the position and motility of the globe but were independent of the size of the defect, and prevented a balanced judgement of the outcome of conservative treatment. Between January 2000 and December 2007, 48 of 127 patients were included in this retrospective study to analyse the functional outcome of orbital fractures managed without operation. Selection was dependent on the availability of complete clinical records, post-traumatic computed tomographic (CT) scans (axial and coronal sections) and ophthalmic examination. All 48 defects were analysed and allocated to categories of a semiquantitative classification. The area of fracture of each defect was calculated with an integral calculus or geometrical formula and correlated with the associated category. Category A included all orbital walls as a single unit (A1) and combined fracture patterns (A2 and higher). Category B described isolated fractures of the medial wall. There was a significant correlation between classes A1 and A2 (p<0.01) and absolute area of the fracture (0.98 (0.4)cm(2) and 2.42 (0.8)cm(2)). Diplopia was most often seen in fractures in category B1 (the anterior third of the medial wall) and the post-traumatic position of the globe significantly correlated with the area of the fracture (p=0.04). The degree of diplopia was less severe in fractures of the posterior portion of the orbit (zones 2 and 3) compared with fractures of the anterior orbit, even if the defect was larger. The conservative management of category A1-3 and B1-3 fractures up to 2.42 (3.15)cm(2) showed no functional impairment, provided that enophthalmos was less than 2mm and there was no entrapment of periorbital tissue or extraocular muscles. We found good correlation between enopthalmos and the size of the fracture, but not for diplopia or motility of the eye. We conclude that conservative management of an orbital fracture in which the defect is less than 3cm(2) has a low risk of permanent functional damage if enophthalmos is less than 2mm and entrapment of soft tissue or muscles is excluded.
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            A peculiar blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: A case report and review of the literature

            Summary Background: Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event. Case Report: A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired. Conclusions: Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.
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              Functional outcome after non-surgical management of orbital fractures — the bias of decision-making according to size of defect: Critical review of 48 patients

                Author and article information

                Journal
                J Emerg Trauma Shock
                J Emerg Trauma Shock
                JETS
                Journal of Emergencies, Trauma, and Shock
                Medknow Publications & Media Pvt Ltd (India )
                0974-2700
                0974-519X
                Jul-Sep 2015
                : 8
                : 3
                : 172-173
                Affiliations
                [1]Department of Emergency, Atatürk Research and Training Hospital, Izmir Katip Çelebi University, Izmir, Turkey
                [1 ]Department of Radiology, Atatürk Research and Training Hospital, Izmir Katip Çelebi University, Izmir, Turkey E-mail: yesimakyol@ 123456gmail.com
                Article
                JETS-8-172
                10.4103/0974-2700.145409
                4520035
                26229305
                e2dde680-27d2-468f-8ef9-dba57110562e
                Copyright: © Journal of Emergencies, Trauma, and Shock

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Emergency medicine & Trauma

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