Tracey Quail Davidoff, MD, FCUCM
A 55-year-old male presents to Urgent Care following a slip and fall in the bathroom in a hotel room the day before. The patient reports that he struck the lateral side of his cheek on the corner of the sink. There was no loss of consciousness. The fall was witnessed by his partner who reports the patient was dazed for a few seconds but then normal. The patient immediately developed swelling and ecchymosis in the area that improved slightly with ice and ibuprofen. The patient was not feeling badly, so he went about his normal activities.
The next day the patient attended a theme park, going on rides including roller coasters. At midday, he felt congested and blew his nose. While doing this, he felt a bubbling sensation in his left cheek and noticed immediate swelling under his left eye. His eye then became nearly swollen shut. He reports no change in vision if he pries his eyelids apart. Otherwise, the eye lid is obstructing his view. He has a mild headache, no nausea, no dizziness, no weakness or numbness of the extremities. He had no nosebleed at any point. He has no significant past medical history and is not on any form of anticoagulation including aspirin.
Exam reveals a well-developed, well-nourished healthy appearing male in no distress, but with obvious facial trauma. His is awake, alert, and oriented x 3, and his partner states he is acting completely normal and himself without personality change. Vital signs and visual acuity are normal. There is swelling and bruising around the left eye, with tenderness to the inferior orbital ridge and the zygomatic arch. There is crepitus in the soft tissue under the eye, but not to the bony areas. The opening of the eye is a slit. The lids are easily parted manually revealing a normal globe without subconjunctival hemorrhage or hyphema. The pupil is normal and reactive to light and accommodation. Extraocular muscles are intact in all directions without pain or diplopia. The external nose is normal, there is no bleeding in the nostrils, the nasal septum is midline, and there is no septal hematoma. There is no other trauma noted.
What is the best Urgent Care management of this patient?
Based on history and exam, this patient likely has an orbital floor fracture, and possibly a zygomatic arch fracture. The swelling of the face and bubbling in the soft tissues is subcutaneous emphysema that came from air being forced out of the fracture line in the roof of the maxillary sinus when the patient blew his nose. Although very frightening for the patient, and dramatic appearing in the clinic, these injuries are relatively benign, if there is no injury to the globe or the intraocular muscles.
Orbital floor fractures — Fractures of the floor of the orbit, sometimes known as “blowout fractures,” typically occur when the eye socket is struck by a fast moving, hard object such as a fist or a baseball. Due to forces transmitted, and the thin bone of the orbital floor compared to the other sides of the orbit, the most common wall ruptured is the orbital floor, which also serves as the “ceiling” of the maxillary sinus. The sinus may fill with blood which may be seen on plain X-ray or CT scan.
Many patients with an orbital floor fracture will have symptoms of only bruising and swelling. However more severe cases may have entrapment of the inferior rectus muscle and/or orbital fat. Ischemia and subsequent loss of muscle function may occur either because of entrapment of muscle within the fracture fragment (more likely in children) or as the result of edema and hemorrhage of muscle and extraocular fat that have prolapsed through the fracture into the maxillary sinus (more likely in adults). Patients with these complications will have gross loss of movement of the extraocular muscles with pain on testing. Orbital dystopia (the eye on the affected side is lower in the horizontal plane than the other) may occur because entrapped muscle and orbital fat pull the eye downward.
Injury to the infraorbital nerve may occur as the result of an orbital floor fracture. This results in decreased sensation along the cheek, upper lip, or upper gingiva.
Trauma to the globe itself must be excluded immediately in all patients with these injuries as it may result in permanent loss of vision. These injuries include: a ruptured glove, orbital hematoma, optic nerve sheath hematoma, retinal detachment, and hyphema. Every effort should be made to gently pry apart swollen eyelids and inspect the globe beneath, as well as assess and document visual acuity. Care should be taken not to put pressure on the eye, which, in the presence of a globe rupture, could cause extrusion of intraocular contents. If this is not possible in the Urgent Care setting, the patient should be referred to the hospital for further evaluation.
Common signs and symptoms of orbital fracture include bony tenderness and swelling, periocular ecchymosis, diplopia, decreased sensation in the distribution of the infraorbital or supraorbital nerves, and/or orbital emphysema. Injury to the lacrimal duct should also be excluded. A focused examination of the facial bones, soft tissues surrounding the eye, and the eye itself should be performed. The eye should be examined with visual acuity performed as quickly as possible because soft tissue swelling may make it difficult for the patient to open their eyes or for the clinician to separate the eyelids.
Examination of the eyelids and surrounding soft tissue may demonstrate crepitus, indicating orbital emphysema as the result of fracture into a sinus. Injury to the lacrimal ducts can occur as the result of lacerations or soft tissue injury along the medial canthus. Decreased sensation indicates injury to the supraorbital nerve (forehead) or infraorbital nerve (cheek).
Pupillary reactivity, size, and shape, as well as extraocular movements and visual acuity should be evaluated. Funduscopic examination may identify vitreous hemorrhage or retinal injury. Finally, a slit-lamp examination should be performed if possible. Injuries that may be identified more easily with the slit-lamp include hyphema, iritis, lens dislocation, and ruptured globe.
The following features are indications of significant, vision threatening eye injury and should prompt immediate emergency evaluation.
The remaining facial bones should be carefully palpated, and any abnormality documented. Tenderness, crepitus, and step-offs on palpation of the malar eminences, zygomatic arches, or orbital rims may indicate an underlying fracture.
Imaging — Plain films are very unreliable and may miss orbital fractures about 50% of the time, limiting their usefulness. They should not be performed in Urgent Care. If it is determined imaging is necessary, computed tomography (CT) should be performed. Patients without findings of complicated injuries can be imaged as outpatients. Patients with concerns of possible complicating factors should be scanned emergently the same day either as outpatients or if not possible, the emergency department.
Initial Management
The initial priority for the management of patients with orbital fracture is to identify and treat life-threatening conditions. The second priority is to ensure there are no vision threatening injuries, as listed above. Most non-displaced orbital fractures without evidence of complication do not require operative repair and can be treated conservatively.
This would include ice, elevation by elevating the head of the bed or recliner 45 degrees to reduce swelling, avoidance of nose blowing or snorting, and pain management with acetaminophen or ibuprofen. Narcotic pain medication should be avoided if there is any question of head injury. The patient should be discharged to the care of a competent adult who can observe the patient for complications of the orbital fracture or head injury.
In the past, patients with sinus fractures were routinely treated with antibiotics, however evidence of benefit of prophylactic antibiotics is lacking. More recent evidence from small observational studies suggests that the risk of infection in adult patients with this injury is quite low and that antibiotic prophylaxis is not necessary, although it may be reasonable for patients with recent sinusitis, immunocompromise, or uncertain follow-up. If antibiotics are prescribed, suggested regimens are the same as for patients with sinusitis.
Phone consultation with an ophthalmologist or facial trauma specialist prior to discharge can help facilitate close follow-up and to determine the timing of imaging. Any patients who seem unreliable, cannot be observed, or have any concerns of complications should be evaluated in the nearest appropriate emergency department. This would include intoxicated patients, elderly patients, homeless patients, those living alone without support, patients with multiple trauma, and victims of violence.
Conclusion of the Case
This patient was visiting from out of town and had no health insurance. He was returning home the following day. He was offered local specialty referral or evaluation at a local free-standing emergency department, which he declined. He was told to ice, elevate, and take ibuprofen, and to seek specialty care upon returning home, contact his primary care physician to help arrange this, if necessary, or to go to his local emergency department. The patient’s spouse was with him and agreed to observe the patient for signs of head trauma and complications. He was given amoxicillin/clavulanate.
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