Orbital Emphysema: Is it Due to Primary Blast Injury or Nose Blowing? A Case Report

Abstract

The authors wish to discuss the possibilities and pathophysiology of orbital emphysema of a live victim of high-explosive blast attack. A 35-year-old male suffered a terrorist blast resulting in shrapnel injuries, flash-burns and bilateral ear drum perforation.  Throughout in a conscious and rational state, he was taken to the nearest tertiary-care hospital. Two shrapnels were surgically removed and all external injuries cleaned and dressed. Swollen left eye was examined by the ophthalmologist to reveal unilateral subcutaneous emphysaema and diplopia but no orbital wall fracture was detected. Specialized ENT referral revealed bilateral central eardrum perforation with impaired hearing. Treating clinicians have already attributed all injuries to the effects of the blast, by the time the Forensic Specialists examined the patient for medico-legal purposes. The forensic specialists were reluctant to attribute orbital emphysema to the effects of the initial blast. Detailed history from the examinee revealed an incident of forceful and violent nose-blowing immediately after the blast to relieve the abnormal sensation he felt within his ears. We discuss here the pathophysiology of orbital emphysema and possible mechanisms of its causation. In conclusion, we emphasize the need for careful interpretation of injuries specially in complex situations such as bomb blasts to prevent attribution of erroneous aetiological factors.