See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/308561871 Acute Subperiosteal Hematoma of the Orbit with Visual Impairment: An Unconventional Presentation Article in Kathmandu University Medical Journal · January 2016 CITATION READS 1 10 3 authors , including: Tripti Maithani Apoorva kumar Pandey Shri Guru Ram Rai Institute of Medical and Health Sciences Shri Guru Ram Rai Institute of Medical and Health Sciences 26 PUBLICATIONS 24 CITATIONS 15 PUBLICATIONS 15 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: parotidectomy View project neck epidermoid cyst View project All content following this page was uploaded by Tripti Maithani on 04 May 2018. The user has requested enhancement of the downloaded file.
KATHMANDU UNIVERSITY MEDICAL JOURNAL Acute Subperiosteal Hematoma of the Orbit with Visual Impairment: An Unconventjonal Presentatjon Maithani T, Singh VP, Pandey A Department of ENT Shri Guru Ram Rai Instjtute of Medical & Health Sciences ABSTRACT Patel Nagar, Dehradun, India. Acute subperiosteal hematoma of orbit is a rare conditjon and its presentatjon with rapid severe diminutjon of vision is even rarest. Urgent interventjon is required for these patjents presentjng with visual compromise. Needle aspiratjon is safe and Corresponding Author simple procedure for management of such hematoma provided the patjent presents early and does not have any associated complicatjons. We present one such rare Triptj Maithani case highlightjng the importance of tjmely diagnosis and urgent management to Department of ENT overcome functjonal complicatjons in acute subperiosteal hematoma. To best of our knowledge this is the fjrst pediatric case presentjng with acute subperiosteal Shri Guru Ram Rai Instjtute of Medical & Health Sciences hematoma accompanied by severely diminished vision within few hours of trauma. Patel Nagar, Dehradun, India. E-mail: dr_triptjmaithani@yahoo.com KEY WORDS Needle aspiratjon, subperiosteal hematoma, visual acuity, Citatjon Maithani T, Singh VP, Pandey A . Acute subperiosteal hematoma of the orbit with visual impairment: an unconventjonal presentatjon. Kathmandu Univ Med J 2016;53(1):84-6. INTRODUCTION Orbital hematoma can be anatomically classifjed as was no signifjcant past medical or surgical history. His examinatjon revealed difguse sofu tjssue swelling in right intraorbital (intraconal/extraconal) or subperiosteal, of which the former is more common. 1 Subperiosteal malar region, there was no actjve nasal or oral bleeding, hematoma (SpH) of the orbit is a rare conditjon which usually no palpable bony crepitus or trismus. Bite of patjent was normal. Ophthalmic examinatjon of right eye revealed mild occurs due to blunt injury to orbit following craniomaxillo facial trauma. The presentatjon of SpH can be acute or proptosis, lateral dystopia with restricted upward gaze (fjg. 2a) whereas lefu eye was normal. Anterior segment chronic. Its symptoms include painful unilateral proptosis, generally inferolateral displacement of globe, absence of examinatjon revealed a sluggish pupillary reactjon in ecchymosis with mild diminutjon of visual acuity. We here right eye with grade I relatjve afgerent pupillary defect. On examinatjon of posterior segment, no disc oedema present a rare case of acute SpH presentjng with rapidly progressive proptosis accompanied with severe diminutjon was seen, cup disc ratjo was 0.3 with healthy neuroretjnal rim and macula was found to be healthy. His visual acuity of vision within hours of blunt facial trauma. Owing to its rapid onset and visual afgectjon we would like to state that was countjng fjngers from 20 cms distance in right eye this case had an unconventjonal presentatjon. whereas 6/6 in lefu eye. Exopthalmometry revealed 2 mm proptosis in right eye. Intraocular pressure was 24.4 mm Hg (by Schiotz tonometer) in right eye and 17.3 mm Hg CASE REPORTS in lefu eye. Evaluatjon by neurosurgeon was done and no intracranial abnormality was detected. The patjent was A nine years old male child presented in ENT out patjent hospitalized and subjected to routjne blood and urine department with chief complains of swelling of face right examinatjons including coagulatjon profjle, CECT of orbit side, accompanied with swelling, pain and reduced vision and paranasal sinuses with 3D reconstructjon of face, in right eye. He had history of trauma to right side of face along with B scan ocular Ultrasound. The CT scan (fjg. 1) following fall on road in the morning same day. There Page 84
Case Note VOL. 14 | NO. 1 | ISSUE 53 | JAN-MAR 2016 Figure 1. A preoperatjve CT scan of face (a) coronal scan reveals a Figure 2. (a) preoperatjve picture showing proptosis and lateral fusiform , sharply defjned, extraconal ,non enhancing mass( bold dystopia of right eye (b) intraoperatjve picture showing needle black arrow) along the right superior orbital margin, displacing aspiratjon of hematoma (c) about 7cc of altered blood was the orbital contents in downwards directjon (b) sagitual scan aspirated(d) postoperatjve picture shows normal positjon of showing obliteratjon of central orbital space and compression right eye of optjc nerve by the mass(black arrow) of orbit and paranasal sinuses revealed a fusiform, sharply Major characteristjcs of SpH are sudden onset of unilateral proptosis, downward displacement of globe, motjlity defjned, extraconal, non- enhancing mass with a broad base along the right superior orbital margin. The mass was impairment, diplopia, absence of ecchymosis and majority homogenous in appearance. It was seen abuttjng the bone of tjmes visual acuity is only mildly decreased. 4 However in our case apart from the usual features the visual acuity and displacing the orbital contents in downwards directjon and causing compression of optjc nerve. However there was markedly afgected. The reason for decreased vision in SpH might be the increased intraocular pressure and was no discontjnuity or fracture of skull bones. The USG- B scan of right eye was normal. Blood and urine examinatjon direct compression of optjc nerve and/or nutrient vessels revealed no abnormality. Based on these fjndings a diagnosis supplying the nerve. 5 of posturaumatjc acute SpH of right orbit was established. Till date there are no fjxed protocols for treatment of this In view of reduced visual acuity of right eye the patjent conditjon. Conservatjve management is recommended in was posted for urgent decompression of hematoma. He cases where the hematoma is insignifjcant with unafgected underwent needle aspiratjon of hematoma (fjg. 2b) under visual acuity. 6 Urgent surgical interventjon is required for general anesthesia. A20G, 1.5 inch needle on 10 cc syringe patjents presentjng with visual compromise, as was seen was inserted along superior orbital margin just lateral to in our case. Reversal of severe visual impairment following superior orbital notch right up to the bone and then the decompression has been reported in literature. 5 Drainage needle was gently withdrawn tjll the blood appeared in the of hematoma can be done by needle aspiratjon or surgical syringe. About 7 cc of altered blood was aspirated (fjg. 2c). evacuatjon. In our opinion if the patjent presents early Proptosis of right eye resolved immediately. Postoperatjve without any associated complicatjons like fracture of period was uneventgul with visual acuity revertjng to orbital roof or subgaleal hematoma then the treatment 6/6 in right eye and normal extraocular movements (fjg. of choice should be needle aspiratjon of hematoma. Late 2d). Patjent is maintaining a regular follow-up and is presentatjon (where the hematoma becomes organized) or asymptomatjc eight months following surgery. associated complicatjons require surgical exploratjon. The merits of needle aspiratjon are simplicity of procedure and avoidance of a facial scar. Since our patjent presented early DISCUSSION and did not have any associated complicatjons, he was SpH of orbit is a rare but well documented clinical entjty. managed by needle aspiratjon with a satjsfactory outcome. The various documented etjological factors are trauma which can be direct or transmitued, barometric, vascular CONCLUSION lesions, hematological disorders and idiopathic. 2 In children the commonest cause of traumatjc SpH is blunt trauma Acute orbital Subperiosteal hematoma is a rare entjty and related to falls or direct impact . 3 It almost always presents can pose serious visual problems in patjents. Such patjents in superior orbit due to mechanical disruptjon of small should be kept under observatjon and visual acuity should vessels under the periosteum. The reason for frequent be monitored. Surgical interventjon, when required, development of hematoma in children is weak adherence depends upon the tjme of presentatjon and associated of the perorbita to the roof of orbit thus it is easier for complicatjons. Timely decompression of the orbit reverts post traumatjc bleed to collect here and form hematoma. back the visual loss. Similar was the etjology in our case also. Page 85
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