Tension Pneumocephalus and Tension Orbital Emphysema Following Blunt Trauma,☆☆,

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Abstract

We present the first reported case of vision loss due to tension orbital emphysema associated with tension pneumocephalus resulting from blunt trauma. In the setting of trauma, intraorbital air indicates paranasal sinus–orbital communication. Tension orbital emphysema may cause vision loss through optic nerve compression, ischemia, or contusion; or central retinal artery occlusion. Vision impairment after craniofacial injury should prompt urgent computed tomography. Tension orbital emphysema with associated vision impairment requires treatment including direct decompression and, in some cases, high-dose steroids to preserve vision. Increases in sinus pressure from coughing, nose-blowing, or vomiting should be avoided until definitive treatment can be instituted. [Wood BJ, Mirvis SE, Shanmuganathan K: Tension pneumocephalus and tension orbital emphysema following blunt trauma. Ann Emerg Med October 1996;28:446-449.]

Section snippets

INTRODUCTION

Intracranial or orbital air resulting from trauma is a sign of fracture extending into a paranasal sinus and is usually harmless and self limiting.1 Pneumocephalus occurs in about 8% of paranasal sinus fractures2, 3, and orbital emphysema is seen on conventional radiographs in two thirds of patients with orbital fractures.4 Orbital emphysema was recently implicated as a rare cause of posttraumatic vision loss.1, 5, 6, 7, 8 Intracranial and orbital air may develop tension if the fracture

CASE REPORT

A 28-year-old man presented after a motor vehicle crash with closed-head injury and transient loss of consciousness. On his arrival at an outside institution, visual acuity was intact and pupils equally round, reactive, and responsive to light. However, he complained of gradual onset of blurred vision and pain in the left eye over a period of hours and was transferred to our Level I trauma center.

On the patient's admission, blood pressure was 150/98 mm Hg, pulse 74, and respirations 20. The

DISCUSSION

Orbital emphysema may cause vision loss through optic nerve contusion, compression, or ischemia1; or as a result of central retinal artery occlusion.6 The onset of blindness classically occurs after nose-blowing, coughing, sneezing, emesis, or a Valsalva maneuver. These activities suddenly increase sinus pressure, transmitting air through the fracture and into the orbit.1, 8 The same mechanism may produce pneumocephalus in the setting of fracture.

Obviously, optic nerve or retinal artery

References (23)

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  • Cited by (0)

    From the Department of Radiology*, and Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; and the Department of Radiology, Georgetown University Medical Center, Washington DC§.

    ☆☆

    Address for reprints: Stuart Mirvis, MD, Department of Radiology, University of Maryland Medical Center, 22 Greene Street, Baltimore, Maryland 21201, 410-328-8845, Fax 410-328-0641

    Reprint no. 47/1/76437

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