Orbital emphysema is an abnormal condition in which air is present within the orbit. We report a rare case of a 19-year-old man who suffered syncopic attacks caused by sniffles following orbital emphysema as a result of trauma. Treating rhinitis is important in patients with orbital emphysema, and patients with cardiac disorders in addition to those with this condition must be warned about the risks of sniffles, sneezing, or nose blowing

Hirai, Misato

Kumase, Fumiaki

Miki, Kentaroh

Nakai, Kiyoko

Narita, Akiko

Noyama, Yasuyuki

Orita, Yorihisa

Seguchi, Jiroh

Sugaya, Akiko

Okayama University Digital Information Repository

Orbital Emphysema Causing Syncope

Okayama University Scientific Achievement Repository

rbital emphysema results from fractures aﬀect-ing the paranasal sinuses and orbital walls,  and orbital trauma,  sneezing,  nose blowing,  and pressure changes during air travel can all act as predisposing factors to this condition [1-7].  Most cases are other-wise asymptomatic and show good outcomes,  although optic nerve damage can occur [4,  5,  8,  9].  The present case report describes a patient with orbital emphysema who suﬀered syncopic attacks when snif-ﬂing.Clinical Presentation　 A 19-year-old man presented to our department because of left eye injury incurred during boxing exercise.  He complained of slight diplopia,  left nasal bleeding,  and a feeling of something wrong with the left eye when sniﬄing or blowing his nose.  On arrival,  his vital signs were stable and nasal bleeding had already stopped.  Examination revealed periorbital edema with ecchymosis and a marked limitation of eye movement.  The nasal mucosa was pale and edematous,  and allergic rhinitis was suspected.  Examination by ophthalmologists revealed that visual acuity (right vision: 0.08 (1.2×－5.0 Diopter),  left vision: (1.2×－4.50 Diopter,  Cylinder －1.0,  Diopter Axis 180)) and intraocular pressure (right: 13mmHg,  left: 12mmHg) were normal,  with no relative aﬀerent pupillary defect.  Although limitation of eye movement in all directions was apparent,  the Hess screen test was almost normal.  Computed tomography (CT) revealed a suspected fracture in the ethmoidal wall of the left orbit and extensive conﬂuent orbito palpebral emphysema (Fig.  1),  but no abnormalities in the brain.  During these examinations,  the patient suﬀered four episodes of syncope while sniﬄing,  with recovery to full consciousness within a few seconds.  The patient had never been treated for allergic rhinitis,  and he could not seem to help from sniﬄing.  He reported no previous history of loss of consciousness.  The family history was negative for epilepsy.  Electrocardiography yielded normal results.  Although OOrbital Emphysema Causing SyncopeKentaroh Mikia＊,  Yorihisa Oritaa,  Fumiaki Kumaseb,  Akiko Sugayaa,   Misato Hiraia,  Yasuyuki Noyamaa,  Kiyoko Nakaia,  Akiko Naritab,   and Jiroh SeguchibDepartments of aOtolaryngology-Head and Neck Surgery,  and bOphthalmology,   Okayama Saiseikai General Hospital,  Okayama 700-8511,  JapanOrbital emphysema is an abnormal condition in which air is present within the orbit.  We report a rare case of a 19-year-old man who suﬀered syncopic attacks caused by sniﬄes following orbital emphy-sema as a result of trauma.  Treating rhinitis is important in patients with orbital emphysema,  and patients with cardiac disorders in addition to those with this condition must be warned about the risks of sniﬄes,  sneezing,  or nose blowing.Key words: emphysema,  syncopic attack,  sniﬄe,  trauma,  vagovagal reﬂexActa Med.  Okayama,  2011Vol.  65,  No.  1,  pp.  55ﾝ57CopyrightⒸ 2011 by Okayama University Medical School.Case Report http ://escholarship.lib.okayama-u.ac.jp/amo/Received May 17, 2010 ; accepted September 10, 2010.＊Corresponding author. Phone : ＋81ﾝ86ﾝ252ﾝ2211; Fax : ＋81ﾝ86ﾝ255ﾝ2224E-mail : iversonphilly3den3det1@yahoo.co.jp (K. Miki)each period of loss of consciousness lasted only a few seconds,  he was admitted to our hospital.  Prophylactic antibiotic therapy was administered for 5 days.  He used ﬂuticasone propionate spray and placed a tampon at the nasal vestibule to prevent sniﬄes or nose blowing.  No episodes of syncope have since been noted.  After 6 days of hospitalization,  the patient was discharged.  Vision gradually returned,  and no ocular abnormalities were observed at the one-month follow up.Discussion　 The vast majority of patients with orbital emphy-sema due to traumatic or atraumatic causes are other-wise asymptomatic,  with resolution of the emphysema occurring without adverse sequelae [4].  Rare but serious complications include retinal artery occlusion and optic nerve ischemia,  leading to visual loss,  so clinicians should not delay examination of the eyes [8].  Although the present case appeared with no visual problems but slight diplopia,  a brief loss of consciousness occurred at the time of sniﬄing.  The duration of the loss of consciousness was only a few seconds each time and no post-ictal confusion or head-ache was reported.　 We identiﬁed three possibilities regarding the pathophysiology behind this symptom.  First,  rectus muscle entrapment into the fracture of the lamina papyracea may have occurred,  and the act of sniﬄing,  which encourages upper air streams of inspired air into the olfactory groove [10],  forced nasal air onto the impacted muscle and caused a vagal response,  although CT did not clearly reveal impaction of the muscle.  Second,  sniﬄing causes negative intranasal pressure [11],  and the pressure may have been strong enough to pull rectus muscle into the intranasal side [12] through the fracture of the lamina papyra-cea,  thus triggering the vagovagal reﬂex.  A number of intraoperative cardiac arrests from the oculocar-diac reﬂex caused by traction on extraocular muscles have been reported in the literature,  and some of them have been fatal [13].  Finally,  the fracture of the lamina papyracea may have produced a valve eﬀect that allowed air to enter but not leave the orbit,  resulting in a high intraorbital pressure [14,  15].  Sniﬄing might then have extremely elevated the intraorbital pressure,  causing a loss of consciousness via the vagovagal reﬂex.  Eyeball pressure is known to pro-duce bradycardia,  and the ocular compression test is sometimes useful to distinguish epilepsy from syncope due to vagal hyperactivity [16].  Since ocular com-pression can sometimes trigger cardiac arrest,  this test should be performed by a cardiologist in a spe-cialized unit,  particularly in the case of individuals with a history of severe cardiac disorder [16,  17].　 Nasal diseases such as allergic rhinitis must be treated to avoid sniﬄes,  sneezing,  or nose blowing,  which can cause changes in intranasal pressure,  and special attention should be paid to the patients with orbital emphysema who have severe cardiac disor-ders.　 Conclusion. We have reported a rare case of orbital emphysema causing syncope.  Patients with orbital emphysema must avoid elevations of orbital pressure.References 1.  Tsai SH and Chu SJ: Orbital emphysema.  J Trauma (2008) 65: 1200. 2.  Lu TC,  Ko PC,  Ma MH and Chen SC: Delayed orbital emphy-sema as the manifestation of isolated medial orbital fracture.  J Emerg Med (2006) 31: 223-224. 3.  Gonzalez F,  Cal V and Elhendi W: Orbital emphysema after sneezing.  Ophtal Plast Reconstr Surg (2005) 21: 309-311.56 Acta Med.  Okayama　Vol.  65,  No.  1Miki et al.Fig. 1　 A coronal CT scan showing a defect in the left lamina papyracea (narrow arrow) with left orbital emphysema (wide arrows). 4.  Rosh AJ and Sharma R: Orbital emphysema after nose blowing.  J Emerg Med (2008) 34: 327-329. 5.  Mohan B and Singh KP: Bilateral subcutaneous emphysema of the orbits following nose blowing.  J Laryngol Otol (2001) 115: 319-320. 6.  Monaghan AM and Millar BG: Orbital emphysema during air travel: a case report.  J Craniomaxillofac Surg (2002) 30: 367-368. 7.  Castelnuovo P,  Mauri S and Bignami M: Spontaneous compres-sive orbital emphysema of rhinogenic origin.  Eur Arch Otorhinolaryngol (2000) 257: 533-536. 8.  Jordan DR,  White GL Jr,  Anderson RL and Thiese SM: Orbital emphysema: a potentially blinding complication following orbital fractures.  Ann Emerg Med (1988) 17: 853-855. 9.  Papadimitriou P,  Ntomouchtsis A and Antoniades K: Delayed traumatic ocular emphysema: a case report.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod (2006) 102: e18-e20.10.  Leong SC,  Chen XB,  Lee HP and Wang DY: A review of the implications of computational ﬂuid dynamic studies on nasal airﬂow and physiology.  Rhinology (2010) 48: 139-145.11.  Stell IM,  Polkey MI,  John Rees P,  Green M and Moxham M: Inspiratory muscle strength in acute asthma.  Chest (2001) 120: 757-764.12.  Uldry C and Fitting JW: Maximal values of sniﬀ nasal inspiratory pressure in healthy subjects.  Thorax (1995) 50: 371-375.13.  Ghai B,  Makkar JK and Arora S: Intraoperative cardiac arrest because of oculocardiac reﬂex and subsequent pulmonary edema in a patient with extraocular cysticercosis.  Paediatr Anaesth (2006) 16: 1194-1195.14.  Garcia-Medina JJ,  Garcia-Medina M and Pinazo-Duran MD: Severe orbitopalpebral emphysema after nose blowing requir-ing emergency decompression.  Eur J Ophtalmol (2006) 16: 339-342.15.  Shinohara H,  Shirota Y and Fujita K: Implication of diﬀerences in the incidence of orbital emphysema in ethmoidal and maxillary sinus fractures.  Ann Plast Surg (2004) 53: 565-569.16.  Gelisse P,  Seraﬁni A,  Davy JM,  Balbe M,  Coubes P and Crespel A: Video-EEG in syncopal attack due to ocular compression in adolescent mistreated for epilepsy.  Epileptic Disord (2007) 9: 174-178.17.  Jaeger FJ,  Schneider L,  Maloney JD,  Cruse RP and Fouad-Tarazi FM: Vasovagal syncope: diagnostic role of head-up tilt test in patients with positive ocular compression test.  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Orbital Emphysema Causing Syncope

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