A peculiar blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: A case report and review of the literature.

BACKGROUND: Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event. CASE REPORT: A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired. CONCLUSIONS: Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.

Salivary gland calculi - contemporary methods of imaging.

Sialolithiasis is the most common disorder of major salivary glands. The main site of salivary stones' formation is submandibular gland, followed by parotid and sublingual gland. The aim of this article was to present current diagnostic imaging modalities carried out in patients suspected with salivary stones on the basis of own material and review of literature.Current diagnostic imaging tools used in the imaging of salivary stones were described and illustrated in this paper. These are: conventional radiography, sialography, ultrasonography, computed tomography, magnetic resonance sialography and sialoendoscopy.Digital subtraction sialography and ultrasonography are the methods of choice in the imaging of salivary gland calculi. Although sialography is a very old diagnostic method, still it is the best diagnostic tool in the imaging of subtle anatomy of salivary gland duct system. Digital subtraction sialography can show the exact location of salivary stone and enables imaging of salivary ducts' pathology (e.g. stenoses), which is especially important when sialoendoscopy is planned. Sialography is also used as the treatment method, i.e. interventional sialography. Nonenhanced computed tomography is recommended when multiple and tiny salivary stones are suspected. Magnetic resonance imaging is the evolving alternative diagnostic method. In this diagnostic modality there is no need for salivary ducts' cannulation and administration of contrast material. Thus magnetic resonance sialography can also be carried out in the acute sialoadenitis. In the future, sialoendoscopy may become one of the main diagnostic and treatment procedures for salivary duct disorders, especially in salivary stone cases.