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INVESTIGATIONS:
Facial bones X-ray, incl. Caldwell view to assess the orbital floor (tear drop)
and orthopantamogram (OPG, dentation)
Facial CT:
Coronal Images show extensive orbital emphysema with air-fluid level in the right
maxillary sinus. The fluid in the maxillary sinus as attenuation value of 71
consistent with blood. Orbital floor is fractured in multiple places and the patient
has also suffered a comminuted fracture of the nasal bone.
DIAGNOSIS: facial trauma with:
1. orbital floor blow out fracture with entrapment of inferior rectus
2. nasal fracture
3. abrasions
Blowout fracture = isolated fracture of orbital floor presents with pain that increases upon
vertical eye movement
Cause: sudden direct blow to globe with increase in intraorbital pressure transmitted to the
weak orbital floor, often associated with fracture of the thin lamina papyracea
diplopia on upward gaze (entrapment of inferior rectus + inferior oblique muscles)
crepitus after nose blowing
Epistaxis and ecchymosis may also be present (mainly lower eyelid)
Enophthalmus
Orbital emphysema
facial anesthesia, hypaesthesia of the ipsilateral cheek and upper lid, resulting
from disruption of the infraorbital nerve as it traverses the orbital floor!
soft-tissue mass extending into maxillary sinus
complete opacification of maxillary sinus (edema + hemorrhage)
depression of orbital floor
posttraumatic atrophy of orbital fat leads to enophthalmus
MANAGEMENT:
analgesia, nasal decongestant sprays, broad-spectrum oral antibiotics, and ice
packs should all be administered.
urgent referral to facio-maxillary surgeon for exploration and elevation of orbital
floor within 24 h if CT shows entrapped muscle or tissue with signs of diplopia
and gastrointestinal (nausea/vomiting) or cardiovascular symptoms (heart block,
bradycardia or syncope). If no entrapped muscle is suspected, surgical repair of the
orbital fracture can be delayed for 1-2 weeks, and is indicated in cases of cosmetic
deformity or diplopia.
D/W ENT regarding nasal fracture and need of reduction