Traumatic Orbital Subperiosteal Hematoma With Acute Visual Compromise: Role of the Head and Neck Surgeon
Tom Shokri, MD, Vijay A. Patel, MD, Neerav Goyal, MD, MPHFirst Published June 6, 2019 Research Article 
https://doi.org/10.1177/0145561319854743

Abstract

The primary goal was to report our institutional experience of a rare, vision-threatening complication following craniomaxillofacial trauma. A retrospective review was performed between January 2016 and January 2018 to identify 3 patients with traumatic orbital subperiosteal hematoma (OSPH). Visual acuity, intraocular pressures (IOPs), and the need for surgical intervention were abstracted. The age range was 36 to 88 years. Indications for surgical intervention include relative afferent pupillary defect, gaze restriction, visual impairment, and elevated IOP. Preoperatively, IOP range was 15.0 to 25.0. Two patients required OSPH evacuation via a medial brow approach. Follow-up after ocular injury ranged from 25 to 41 days, with IOP range of 13.0 to 16.0. Traumatic OSPH is an uncommon clinical finding; prompt assessment with consideration of surgical intervention may mitigate deleterious long-term morbidity, chiefly sudden blindness. Further research efforts may elucidate the optimal method in the management of this complex clinical entity.

Keywords subperiosteal hematoma, optic neuropathy, orbit, trauma

Introduction

Orbital hematomas have been classically described as either intraorbital or subperiosteal in nature.¹Intraorbital (ie, retrobulbar) hematomas are observed in the setting of craniomaxillofacial trauma and/or orbital approaches^2,3; data reporting their occurrence are sparse, with an estimated incidence of 0.3%.⁴Orbital subperiosteal hematomas (OSPHs) are less common; occurring primarily in young males as a direct result of craniomaxillofacial trauma, although the development of spontaneous OSPH has been reported. The etiologies of OSPH may be divided into 4 subcategories: congestive, traumatic, spontaneous, and systemic.¹ Congestive OSPH occurs with elevated cranial venous pressures and/or venous congestion, while systemic OSPH typically presents in the setting of a bleeding diathesis. If no clinical association can be identified, the OSPH is termed as spontaneous. Several case reports have described the rare entity of traumatic OSPH.^5-7 Despite these findings, there remains a paucity of primary literature addressing the appropriate management of this complex disorder. Currently described treatment options for traumatic OSPH include conservative management, needle aspiration, or surgical intervention. In this study, we characterize our institutional experience of traumatic OSPH and discuss contemporary surgical strategies.

Methods

Patients identified with a documented diagnosis of traumatic OSPH at a tertiary care center. A total of 3 patients were evaluated and treated by both the Division of Otolaryngology–Head and Neck Surgery and the Department of Ophthalmology in the emergency, inpatient, or outpatient settings. Parameters analyzed include age, gender, time to presentation, laterality, visual acuity, preoperative and follow-up intraocular pressures (IOPs), diagnostic imaging, surgical intervention, and time to resolution. The institutional review board of Penn State Hershey Medical Center reviewed the study protocol and deemed it exempt (STUDY00010121).

Results

Clinical Characteristics

A total of 3 patients were found and evaluated for this chief complaint; all patients presented secondary to a mechanical fall. The mean time to presentation was 12 hours, with a delay in evaluation resulting in a suboptimal visual outcome. All patients had initial radiographic evaluation with high-resolution computed tomography (CT). Table 1 describes patient demographics, time to presentation, and clinical features describing each patient encounter. All patients underwent a comprehensive head and neck and ophthalmologic examination with dedicated CT imaging (Figure 1). Indications for surgical intervention included relative afferent pupillary defect, visual impairment, gaze restriction, and elevated IOP; 2 patients required OSPH evacuation under general anesthesia via a medial brow approach. One patient was successfully treated with observant management. He presented with IOP within normal parameters, and no clinical ocular compromises on ophthalmologic examination. He was reevaluated within approximately one month’s time with premorbid visual acuity and confirmed resorption of OSPH on repeat CT imaging.

Table 1. Traumatic Orbital Subperiosteal Hematoma.

Table 1. Traumatic Orbital Subperiosteal Hematoma.

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Figure 1. A 36-year-old man with a right-sided traumatic orbital subperiosteal hematoma (OSPH) after mechanical fall. Computed tomography (CT) coronal (A) and sagittal (B) images reveal a right-sided OSPH with inferior displacement of orbital contents.

Surgical Technique

A 15-blade was used to make a 1.5-cm, trichophytic, medial brow incision. This incision was carried down to the superior orbital rim with cautery through the orbicularis musculature. The periosteum was sharply incised, and a Freer Elevator was used to bluntly elevate the periosteum into the superior orbit, taking care to avoid the supratrochlear neurovascular bundle. Although remaining in a subperiosteal plane, any clot and blood were evacuated using a Frazier suction. Following the evacuation of blood and confirming hemostasis, forced duction testing was performed to confirm intact movement without restriction. For both cases, a Penrose drain was placed. The incision was closed with interrupted absorbable suture.

Discussion

In our series, traumatic OSPH involved the orbital roof; periosteal attachments within this region are not dense and therefore may have less structural integrity except at the suture lines resulting in a potential space where OSPH may develop. Small increases in orbital volume can manifest as ocular proptosis, followed by rapidly rising IOPs and gaze restriction, resulting in compressive optic neuropathy with acute visual compromise.

Classic physical manifestations of traumatic OSPH include ocular proptosis, inferior globe displacement, chemosis without conjunctival hemorrhage, absent lid ecchymosis, and motility impairment with varying degrees of associated visual impairment. The clinical diagnosis is facilitated with the use of CT. Imaging findings include a broadly based lesion with high-attenuation, abutting the frontal bone with gross displacement of orbital contents inferiorly.⁸ Magnetic resonance imaging can also be employed in the nonacute clinical setting which may reveal a biconvex mass that is well-defined with a curvilinear hypointense segment along the superior orbit.^9,10 Orbital subperiosteal hematoma may be managed conservatively; the period of observation is contingent upon the extent of visual impairment and concern for optic neuropathy. Rapid evacuation either via fine-needle aspiration or orbital exploration with drainage has been well-documented.^5-7 Risks certainly exist with fine-needle aspiration including hematoma reaccumulation as well as insufficient drainage. Open approaches allow for complete clot evacuation with the added ability to address sites of active bleeding with pinpoint electrocautery and minimize recurrence with drain placement to provide passive egress.

In our experience, a multidisciplinary approach involving otolaryngology and ophthalmology allowed for timely management of OSPH. The otolaryngologist is likely more comfortable with an open medial brow approach with drain placement, which in our hands allowed ease of exposure, relative safety with respect to key neurovascular structures, and an aesthetically pleasing incision while allowing for a rapid decompression. Timely evaluation and management is crucial in mitigating ocular compromise as evidenced by the poor outcome, despite procedural intervention, seen in the patient who presented following 24 hours from onset of injury. Consequently, referral or transfer to a tertiary care center may not be necessary as it can delay treatment of a time sensitive condition which can potentially be managed by the general otolaryngologist (Figure 2).

Figure 2. Algorithmic approach to diagnostic evaluation and workup of orbital subperiosteal hematoma (OSPH).

Conclusion

Traumatic OSPH is an uncommon clinical entity; prompt assessment with consideration of surgical intervention may mitigate deleterious long-term morbidity, chiefly complete visual impairment. In this series, several factors appear to play a role in pursuing prompt operative intervention, which includes increased IOP, relative afferent pupillary defect, gaze restriction, and vision loss. Prognostic factors that play a role in postoperative outcomes include time to presentation as well as baseline visual acuity. Further studies may elucidate the optimal technique in the management of this complex disorder.

Authors’ Note
This paper was presented as a podium presentation at the AAO-HNSF Annual Meeting; October 9, 2018; Atlanta, GA.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Tom Shokri  https://orcid.org/0000-0002-1123-4385

Neerav Goyal  https://orcid.org/0000-0001-7783-1097

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