Orbital Emphysema

Key Points at a Glance

1. What is Orbital Emphysema?

Orbital emphysema is a condition in which abnormal air accumulates within the orbit or eyelids. It is generally benign and relatively rare, and most cases resolve spontaneously without sequelae within 7 to 10 days.

Orbital wall fracture is the most common cause. The specificity of orbital emphysema for orbital fracture is 99.6%, and the positive predictive value is 98.4%. In particular, it is highly correlated with medial wall fractures, with up to 75% of medial wall fracture cases complicated by orbital emphysema ⁷⁾.

Eyelid emphysema mainly occurs due to trauma and is generally absorbed naturally, healing within a few days. Orbital emphysema is also absorbed naturally within a few days.

Q How long does it take for orbital emphysema to heal?

Most cases resolve spontaneously without sequelae within 7 to 10 days without special treatment. However, in tension orbital emphysema caused by a one-way valve mechanism, it can progress to orbital compartment syndrome, and emergency intervention is required if symptoms of optic neuropathy appear.

2. Main Symptoms and Clinical Findings

Subjective Symptoms

Pressure/pain: Discomfort or pain around the orbit.
Diplopia: Due to extraocular muscle dysfunction or globe displacement.
Changes in vision/visual field: Occurs in severe cases due to optic nerve compression.
Sensation of restricted eye movement: Associated with increased intraorbital pressure.

Clinical Findings

Crepitus: A crackling sensation palpated on the eyelid. Pathophysiologically specific to orbital emphysema.
Proptosis: Even a small amount of air can cause severe restriction of eye movement in all directions.
Hypoglobus: Occurs because free air tends to accumulate in the superior orbit.
Restricted eye movement: Due to increased intraorbital pressure.
Subconjunctival emphysema: Extension of orbital emphysema beneath the conjunctiva. Requires differentiation from lymphangiectasia, chemical burn, and orbital fat prolapse⁷⁾.
RAPD (Relative Afferent Pupillary Defect): A sign of optic nerve dysfunction.
Decreased visual acuity: In severe cases, caused by central retinal artery occlusion (CRAO) or compressive optic neuropathy.

Severity Classification

It is classified into three stages according to the Roelofs classification²⁾.

Mild

Criteria: No optic nerve compression or visual impairment

Management: Conservative management only

Moderate

Criteria: Early signs of optic nerve compression, mild visual impairment, elevated intraocular pressure, moderate proptosis

Management: Needle aspiration ± lateral canthotomy and cantholysis

Severe

Criteria: Significant optic nerve compression, severe visual impairment, elevated intraocular pressure, marked proptosis

Management: Emergency orbital decompression

Q Can orbital compartment syndrome occur even with normal intraocular pressure?

Yes. In a report by Cutting et al. (2021), a case was documented in which RAPD appeared and optic nerve dysfunction occurred despite an intraocular pressure of 12 mmHg (within normal range)⁶⁾. It is important not to judge safety based solely on intraocular pressure values, but to comprehensively evaluate RAPD, visual acuity, and proptosis.

3. Causes and Risk Factors

Orbital emphysema occurs due to various causes. The lamina papyracea, which separates the paranasal sinuses and the orbit, is as thin as approximately 0.3 mm, and it becomes even thinner with aging, osteoporosis, and chronic sinusitis, so even relatively minor force can cause fracture or dehiscence¹⁾.

A comparison of the main causes and pathogenesis is shown below.

Cause category	Typical pathogenesis
Traumatic	Orbital wall fracture (especially medial wall), eyelid/conjunctival laceration
Behavioral/physiological	Nose blowing, sneezing, Valsalva maneuver
Iatrogenic	FESS, rhinoplasty, blepharoplasty, chest tube
Other	Barotrauma, infection, esophageal rupture, idiopathic

Intranasal pressure can reach over 70 mmHg with nose blowing and 176 mmHg with sneezing with mouth and nose closed ⁴⁾, which can cause dehiscence or fracture of the lamina papyracea.

Iatrogenic causes include functional endoscopic sinus surgery (FESS) ³⁾, rhinoplasty ¹⁾, blepharoplasty ⁴⁾, and there have also been reports of air reaching the orbit via the mediastinum and neck through a bronchopleural fistula after chest tube insertion ⁹⁾.

Q Can orbital emphysema occur just from blowing your nose?

It can occur. The intranasal pressure during nose blowing can reach over 70 mmHg, and if the lamina papyracea is thinned due to aging or chronic sinusitis, it can cause dehiscence or fracture ⁴⁾⁶⁾. Even without a history of orbital fracture, there are reported cases of allergic rhinitis patients who blew their nose strongly the day after trauma, worsening orbital emphysema ²⁾.

4. Diagnosis and Examination Methods

Medical History and Physical Examination

The first step is to confirm crepitus by palpation of the eyelid and orbit. This finding is considered specific for orbital emphysema. Always inquire about trauma history, history of sinusitis, recent nose blowing, sneezing, and surgical history.

Imaging Studies

The characteristics of each imaging study are shown below.

Examination	Characteristics	Cautions
Plain X-ray	Suggestive by “black eyebrow sign”	False negative rate 50%, difficult to detect micro-fractures
CT	Most definitive diagnostic method	Both soft tissue and bone windows are required
POCUS	CT alternative, no radiation exposure	Requires specialized equipment and facility

Plain X-ray: A crescent-shaped lucency in the superior orbit, known as the “black eyebrow sign,” is highly suggestive ²⁾⁵⁾. However, the false-negative rate reaches 50%, making it difficult to detect small amounts of air or subtle fractures.
CT: The most definitive imaging method for diagnosing orbital emphysema. It can assess the presence, location, and amount of air, bone defects, optic nerve status, and extraocular muscle entrapment. Imaging along the Reid baseline (RB line) is standard, and adjusting the window width to soft tissue settings facilitates identification of orbital fat and intraorbital emphysema. Evaluation should be performed under both soft tissue and bone window settings.
POCUS (Point-of-Care Ultrasound): Can be used as an alternative to CT when CT is unavailable, such as during surgery or when patient transport is difficult. It can detect air pockets around the eye in real time ³⁾.

Differential Diagnosis

Infection due to gas-producing bacteria: Suspect when fever and leukocytosis are present.
Intraorbital foreign body (wood, polystyrene): Differentiate with CT follow-up.
Orbital abscess due to anaerobic bacteria: Differential diagnosis is necessary when signs of infection are present.
Retrobulbar hemorrhage: After blepharoplasty, pain, ecchymosis, and visual loss are more pronounced, which aids in differentiation ⁴⁾.
Occult malignancy: Consider in cases of recurrent emphysema or without a history of trauma.

5. Standard Treatment

Treatment is selected stepwise according to severity.

Conservative Management (Mild Cases)

Most cases resolve spontaneously without treatment or surgical intervention. The following guidance and symptomatic treatment are provided.

Advise avoidance of nose blowing, sneezing, coughing, and Valsalva maneuver.
Avoid travel to high altitudes (air expands under low pressure) ¹⁾.
Manual expression of air (if there is an opening into the paranasal sinuses).
Analgesics: Used for pain management.
Nasal decongestants and antihistamines: Used to reduce mucosal inflammation and sneezing reflex ¹⁾²⁾.
Prophylactic antibiotics: Used to prevent secondary infection (orbital cellulitis). However, recent retrospective cohort studies suggest they are unnecessary in low-risk groups without upper respiratory infection and not using steroids ²⁾.
Pressure eye patch: Used in some cases.

Pharmacotherapy (Moderate to Severe)

Intravenous methylprednisolone: For compressive optic neuropathy (Hunts classification Stage III–IV). Administer a loading dose of 30 mg/kg, followed by 15 mg/kg every 6 hours ²⁾.

Needle Aspiration (Moderate)

Connect a needle to a syringe containing saline and aspirate air from the orbit. This allows monitoring of air bubble release, preventing tissue damage from aspiration ²⁾⁶⁾.

Cutting et al. (2021) reported a case of recurrent non-traumatic orbital emphysema causing orbital compartment syndrome. They punctured near the lacrimal caruncle with a 16G cannula and aspirated 7 mL of air, resulting in immediate resolution of proptosis and diplopia ⁶⁾.

Surgical Intervention (Severe/Emergency)

Lateral canthotomy ± cantholysis: Performed as an emergency procedure for orbital compartment syndrome.

Chew et al. (2025) performed only lateral canthotomy without cantholysis in a case of orbital compartment syndrome with intraocular pressure reaching 48 mmHg due to tension orbital emphysema. In combination with systemic acetazolamide, intraocular pressure decreased to 28 mmHg, and the patient fully recovered after 5 days ⁵⁾.

Orbital decompression: Indicated for severe cases with RAPD and vision loss.
Hyperbaric oxygen therapy: Occasionally used to promote absorption via nitrogen diffusion gradient ¹⁾.
Surgical closure of sino-orbital fistula and orbital wall fracture repair: Performed as follow-up for underlying disease.

Management Protocol Based on Hunts Classification

In the Hunts classification (Stage I–IV), management is determined based on the presence of vision loss, elevated intraocular pressure, and central retinal artery occlusion ²⁾.

Stage I: No proptosis/displacement, no vision loss, normal IOP, no CRAO → prophylactic antibiotics + decongestants + no nose blowing
Stage II: Proptosis/displacement present, no vision loss, normal IOP, no CRAO → orbital CT + Stage I treatment ± needle aspiration
Stage III: Proptosis/displacement present, vision loss present, IOP elevated (yes/no), no CRAO → orbital CT + immediate needle aspiration + IV methylprednisolone
Stage IV: Proptosis/displacement present, vision loss present, IOP elevated, CRAO present → emergency lateral canthotomy and cantholysis + orbital CT + needle aspiration + IV methylprednisolone

Q How is needle aspiration performed?

This is a procedure in which a syringe filled with saline is connected to a needle (cannula) and air accumulated in the orbit is aspirated. Since the release of air bubbles can be confirmed in real time, tissue damage due to aspiration can be prevented. In a report by Cutting et al. (2021), a 16G cannula was inserted near the lacrimal caruncle, and aspiration of 7 mL of air immediately resolved proptosis and diplopia ⁶⁾.

6. Pathophysiology and Detailed Mechanism

The basic mechanism of orbital emphysema is a one-way valve mechanism in which air enters the orbit but cannot exit and accumulates ²⁾⁵⁾.

The most common route of air entry is from the paranasal sinuses through a fractured or dehiscent lamina papyracea. The damaged orbital fat tissue acts as a valve, preventing air from escaping the orbit.

Elevated intraorbital pressure causes the following visual impairments.

Compressive optic neuropathy: Increased intraorbital pressure compresses and stretches the optic nerve, causing ischemia. Ischemia lasting more than 3 hours creates a risk of permanent vision loss⁵⁾.
Central retinal artery occlusion: Occurs when intraorbital pressure exceeds ophthalmic artery pressure.

In Heerfordt’s cadaver experiments, an internal pressure of 40–50 mmHg was required to rupture the orbital septum when air was injected into the orbit, with the greatest resistance observed in younger individuals²⁾. When orbital–eyelid emphysema (a condition in which the orbital septum ruptures and air spreads into the anterior eyelid) occurs, intraorbital pressure decreases, which can be a negative finding for orbital compartment syndrome²⁾.

The average volume of the adult orbit is approximately 30 mL, a limited conical space. Because the septum and tarsal plate have limited extensibility, the orbit is vulnerable to volume increases⁵⁾.

Air migration from distant sites can also occur. Because the deep fascial planes of the face, neck, and chest are anatomically continuous, cases have been reported in which air reached the orbit via the bronchopleural fistula → mediastinum → neck → inferior orbital fissure⁹⁾.

7. Latest Research and Future Perspectives (Investigational Reports)

Diagnostic Application of POCUS (Point-of-Care Ultrasound)

Kanwat et al. (2024) published the first report of using POCUS for real-time diagnosis and monitoring of periorbital emphysema that occurred after FESS in an 8-year-old child, when intraoperative CT was not available³⁾. The condition completely resolved within 36 hours with conservative treatment (Neosporin ointment, pressure bandage).

POCUS, which is radiation-free and can be used repeatedly, is attracting attention as an alternative diagnostic tool, especially in pediatric cases and emergency situations where CT is not available.

Positional Maneuver

Boustany et al. (2023) reported a case of a 63-year-old woman who developed transient binocular vertical diplopia after rhinoplasty. After performing a left lateral decubitus positional maneuver for 2 hours, a 4 mm × 3 mm extraconal air pocket in the superior orbit was guided toward the inflow site, and the diplopia resolved¹⁾.

This technique applies the principles of the Epley maneuver for benign paroxysmal positional vertigo and the Durant maneuver for air embolism, and has been reported in a limited number of cases as a non-invasive approach for mild extraconal emphysema.

PMMA as a Reconstructive Material for Orbital Floor Fractures

AlSubaie et al. (2022) reported two cases of orbital blowout fractures (BOF) reconstructed using moldable polymethyl methacrylate (PMMA) implants, with good anatomical and functional outcomes at one year postoperatively ⁸⁾. The material is inexpensive, can be molded intraoperatively, and does not require fixation after hardening, but long-term results are unknown.

8. References

Boustany AN, Comer CD, Gopal H, Lin SJ, Slavin SA. Acute diplopia following rhinoplasty: clearing the air. Plast Surg. 2023;31(2):177-182.
Ng QX, Lim XC, Chong JC, Hanafi H, Lim LT. Traumatic orbital emphysema following blunt trauma and nose blowing. Cureus. 2023;15(11):e48584.
Kanwat J, Jalwal G, Rathi U, Kaur K. An innovative use of point-of-care ultrasound for identification and management of a rare and uncommon perioperative complication: periorbital emphysema following sinus surgery in a pediatric patient. Cureus. 2024;16(4):e57721.
Tarim B, Kılıç M. Orbital and premaxillary emphysema as a result of nose-blowing following blepharoplasty. Indian J Plast Surg. 2025;58:136-138.
Chew CF, Prem-Kumar V. Tension orbital emphysema following blunt trauma: a case of orbital compartment syndrome. Cureus. 2025;17(11):e97421.
Cutting S, Davies-Husband C, Poitelea C. Recurrent self-induced nontraumatic orbital emphysema causing orbital compartment syndrome with optic nerve dysfunction. Case Rep Ophthalmol Med. 2021;2021:8884009.
Boyer EF III, Filutowski O, Slonim C. Late subconjunctival emphysema in an unrepaired orbital floor fracture. Cureus. 2022;14(4):e24459.
AlSubaie MF, Al-Sharydah AM, Nassim HM, Alhawsawi A. Orbital floor blowout fracture reconstruction using moldable polymethyl methacrylate: a report of two cases and their imaging findings. Open Access Emerg Med. 2022;14:223-232.
Land MR, Shin EH, Kim DB. Orbital emphysema as a result of chest tube placement for recurrent pneumothorax. Clin Case Rep. 2023;11:e6978.

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