The Subcutaneous Emphysema (SE) is defined as the occurrence of forced passage of air and/or other gases to inside of the soft tissues, below the dermal layer or mucous membranes. The anatomic sites that are most commonly affected include neck, thorax and face. It can also occur the spread of air at a distance through the subcutaneous space, and muscular fascia between the areas involved. The orbital SE is considered a benign disease, mostly self-limited, that presents a spontaneous regression in one to three weeks, however depending on the localization, it can lead to hemodynamic instability. Here we present a case report of exuberant orbital subcutaneous emphysema, diagnosed by the dermatologist, being opted the conservative treatment with total remission of symptoms.
A 62-year-old male patient, businessman, complaining of eye edema in the last few hourspresented at the Emergency Room (ER) after falling from a ladder at 1,80m high in his house. The patient reported pain in the right shoulder, body excoriations and headache; and did not presented symptoms like dyspnea, chest pain and pain in other topographies. He was medicated by the ER staff with intramuscular non-steroidal anti-inflammatory, showing, a few minutes later, bilateral symmetric orbital edema associated with local discomfort. Regarding comorbidities, he was hypertensive and smoker. The physical examination revealed a bilateral eyelid edema, symmetric and painless (Figure 1a), while the local palpation showed the presence of crackling. The patient was treated with antihistamine and corticoid, without any improvement, and he evolved to a progressive worsening of the edema (Figures 1b & 1c). Chest radiography and computed tomography of the skull were did (Figures 2a & 2b).
Figures 1a, 1b & 1c: 1a - Patient at admission presenting bilateral facial and periorbital edema; 1b and 1c -Evolution of the patient, with progressive worsening of the edema.
Figures 2a: Chest X-ray evidencing the subcutaneous emphysema area on the lateral region at right; possible fractures were ruled out.
Figure 2b: Skull computed tomography showing the enlargement of soft areas with diffuse subcutaneous emphysema. Possible fractures were ruled out.
The Department of Dermatology of the Jundiaí Medical School (FMJ) was asked to evaluate the patient considering the diagnostic hypothesis of angioedema. However, facing the clinical picture, physical examination and imaging exams the diagnostic of bilateral orbital subcutaneous emphysema resulting from blunt trauma was performed.
The orbital subcutaneous emphysema was accompanied in an outpatient setting, as it presented clinical stability. It was treated in the symptomatic patients and the antibiotic prophylaxis was performed. At a 10-days-period, the spontaneous remission of the signs and symptoms was observed, without complications (Figures 3a & 3b).
Figures 3a & 3b: Patient 10 days later, showing spontaneous clinical improvement with conservative treatment.
The Subcutaneous Emphysema (SE) is defined as the forced passage of air and/or other gases to the inside of soft tissues, below the dermal layer or mucous membranes . The anatomic sites that are most commonly affected include neck, thorax and face, besides the spread of air at a distance through the subcutaneous space between the areas involved.
The orbital SE presents a low frequency and have as causes the direct trauma to the maxillofacial bone and to the indirect cranioencephalic trauma, barotrauma like in dives [2-4], iatrogeny in dental procedures, such as the removal of the third molars , in otolaryngological procedures , as ethmoidectomy, in facial plastic surgeries as rhinoplasty , and spontaneously like in infections of the upper respiratory tract caused by gas producing microrganisms, vigorous sneezing or after nasal cleanliness and vigorous exercises such as weight lifting [8-10] (Table 1).
To the maxillofacial bone;
Fracture or perforation of one of the orbital and sinus bones.
Dental treatment: extractions, restorations;
Sinus barotrauma (positive pressure ventilation):
- Airplane travel;
- Nasal manipulation:
vigorous sneezing, nasal cleanliness, nose blowing;
- Vigorous exercises:
weight lifting, bungee jumping.
Infections of the upper respiratory tract caused by gas producing microorganisms.
Table 1: Causes of Orbital SE.
The lamina papyracea is a region of the medial wall of the orbit susceptible to trauma, high positive pressures and iatrogenic procedures. Its fracture or dehiscence allows air entrance in the orbital region . Images such as radiography or computed tomography may not show bone fracture . In this case, in the absence of facial trauma, we presume thatincreased intranasal pressure as a result of the fall caused a tear in the congenitally thin or dehiscent laminapapyracea permitting air to enterinto both orbits withsudden and dramatic appearance of emphysema .
The clinical picture of orbital SE is characterized by the increased volume of the orbitary region, pain, erythema and local discomfort. Crackling at palpation is the main clinical sign, which differs this comorbidity from the others [12-13].
The correct diagnosis depends on cautious anamnesis, good physical examination and imaging exams when they are indicated. They are restricted to the evaluation of the extent and facial spaces of affected regions, besides the situations of diagnostic doubt. They have formal indication in the cases that occur a cervical or thoracic volume increase, dyspnea or thoracic pain . Among the exams, we can cite the Radiography, Ultrasonography and Computed Tomography, highlighting the last one due to its high diagnostic accuracy [1,14]. Considering the differential diagnostics, stands out the allergic reactions, bruising, angioedema and infections, like cellulitis .
The orbital SE is considered a benign disease, self-limited in most of cases, that presents spontaneous regression in one to three weeks . The treatment should be conducted at outpatient or hospital settings, being restricted to the cases in which the edema extends to below of the cervical region . The outpatient treatment is based on patient guidance, such as avoid positive pressures, analgesia and antibiotic prophylaxis, due to the increased risk of local infection by the inoculation of microrganisms from the oral cavity into the inside of tissues [17,18]. The surgical intervention - drainage and decompression of the area affected - may be necessary in case of the patient complains about local discomfort, if the thoracic region was affected and when there is a possibility of cardiopulmonary complications . The drainage of the orbital region can be performed by a 24-gauge needle or lateral canthotomy .
Complications are rare, but some of them can be serious and put the patient’s life at risk . Among severe complications we can cite secondary infections, that can evolve to necrosis and necrotizing fasciitis; pneumothorax and mediastinal emphysema, due to the passage of air into the pre-tracheal and retropharyngeal spaces, reaching the thorax and possibly causing hemodynamic instability; compression of the optic nerve by the passage of air into the orbit, which constitutes an ophthalmological emergency [17,22].
The subcutaneous emphysema is a rare condition, often associated with trauma and invasive procedures, not being considered part of the dermatologist routine. We elucidated a case of orbital emphysema, diagnosed by the dermatologist, in which we chose the conservative treatment that led to the total remission of symptoms without complications.