What is the recommended treatment for orbital emphysema?

Treatment of Orbital Emphysema

Most cases of orbital emphysema can be managed conservatively with observation, as the condition is typically benign and self-limiting. 1

Assessment and Classification

• Orbital emphysema occurs when air enters the orbital soft tissues, usually following trauma or surgery to the orbit or paranasal sinuses 2, 1
• Common triggers include sneezing or forceful nose-blowing after an orbital wall fracture 3, 4
• Severity should be assessed based on:
  • Visual acuity
  • Intraocular pressure
  • Ocular motility
  • Proptosis
  • Signs of vascular compromise 2

Treatment Algorithm

Conservative Management (Most Cases)

• Observation for mild to moderate cases without visual compromise 1
• Patient instructions:
  • Avoid nose blowing, sneezing, and Valsalva maneuvers 4
  • Apply cold compresses to reduce swelling 1
  • Prophylactic oral antibiotics if fracture involves an infected sinus 1
• A short burst of oral steroids can help reduce orbital edema and hasten recovery 5

Urgent Intervention (Vision-Threatening Cases)

• Immediate needle decompression is indicated for:
  • Central retinal artery occlusion
  • Compressive optic neuropathy
  • Significant elevation in intraocular pressure
  • Progressive vision loss 3, 2
• Technique: needle-coupled open syringe filled with saline allows direct monitoring during decompression 2

Surgical Management

• Timing of surgical repair depends on clinical presentation:

  • Immediate repair is indicated for:

    • Entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex
    • "White-eyed blow-out fracture" with muscle entrapment (especially in children)
    • Globe subluxation into the maxillary sinus 5

  • Repair within 2 weeks is recommended for:

    • Symptomatic diplopia with positive forced ductions or entrapment on CT
    • Large floor fractures with hypoglobus
    • Progressive infraorbital hypoesthesia
    • Early enophthalmos causing facial asymmetry 5

  • Delayed repair may be considered for:

    • Restrictive strabismus and unresolved enophthalmos 5

Follow-up and Monitoring

• Regular monitoring of visual acuity, intraocular pressure, and ocular motility until resolution 2
• Most cases resolve spontaneously within days to weeks 1, 6
• For persistent diplopia after resolution of emphysema:
  • Conservative options include occlusion, filters, Fresnel prisms, and prism glasses 5
  • If strabismus persists, surgical intervention may be considered after 4-6 months to ensure stability of misalignment 5

Special Considerations

• Atraumatic orbital emphysema is rare but may occur in patients with chronic sinusitis, previous facial surgery, or current upper respiratory symptoms 6
• In cases with associated strabismus, preoperative forced generation testing and intraoperative forced duction testing are important 5
• Fat entrapment can be as challenging as extraocular muscle entrapment and may result in fibrotic adhesion syndromes 5