Experience Summary

Orbital trauma is a significant clinical concern that often involves the Ear, Nose, and Throat (ENT) team, particularly in cases of facial fractures or complex soft tissue injuries. It can cause a variety of clinical presentations from minor bruising, to sight threatening haemorrhage.

This experience allows you to observe the assessment and management of an orbital trauma from the perspective of the ENT surgeon.

Assessment

Initial assessment follows an ABCDE approach, ensuring the patient is stable and addressing life-threatening injuries first. Once stabilised, a focused examination of the orbital region is performed, often in collaboration with ophthalmology and maxillofacial teams.

Key aspects of ENT assessment include:

• Visual Acuity: Testing vision in each eye to identify any compromise.
• Inspection: Looking for periorbital bruising, lacerations, step deformities, or enophthalmos (sunken eye).
• Palpation: Feeling for bony step-offs or crepitus that may suggest fractures, particularly of the orbital rim or floor.
• Eye Movements: Assessing for restricted gaze or diplopia, which may indicate muscle entrapment.
• Pupil Examination: Checking for afferent pupillary defects, which may signify optic nerve injury.
• Sensation: Evaluating infraorbital nerve function, as numbness in the cheek, upper lip, or upper gum can suggest orbital floor involvement.

If orbital compartment syndrome is suspected—characterised by proptosis, tense orbit, reduced vision, and afferent pupillary defect—this is a surgical emergency requiring immediate intervention to prevent vision loss.

Imaging

A CT scan of the orbits and facial bones is the gold standard for assessing bony injuries and soft tissue involvement. This provides essential information for surgical planning.

Management

Management depends on the severity and specific injuries identified:

• Conservative Management: Minor, non-displaced fractures without muscle entrapment, significant enophthalmos, or visual compromise may be managed conservatively with observation, analgesia, and advice to avoid nose blowing to reduce the risk of orbital emphysema.
• Surgical Intervention:
  • Indicated for displaced orbital fractures, muscle entrapment causing diplopia, significant enophthalmos, or in cases of orbital compartment syndrome.
  • The ENT team, often alongside maxillofacial surgeons, may perform orbital decompression or fracture repair, typically via transconjunctival, subciliary, or endoscopic approaches.

Multidisciplinary care, involving ENT, ophthalmology, and maxillofacial teams, is essential to optimise functional and cosmetic outcomes while preventing long-term complications such as persistent diplopia or vision loss.

Learning Outcomes

1. Observe a history taken from a patient presenting with orbital trauma.
2. Observe the assessment of the eye and vision.
3. Understand the potential management options in orbital trauma
4. Observe the counselling points for a patient who may require a lateral canthotomy.

External Resources

• BMJ Best Practice: Eye trauma