Spontaneous periocular ecchymosis: a major review.

Periocular ecchymosis, or periocular bruising, is a common clinical finding. Periocular skin is thin with an extensive vascular network, making this anatomical region prone to bruising. The most common etiology is trauma, but rarely, patients can present with spontaneous periocular ecchymosis (SPE). The pathophysiology of SPE is complex and varied. In this literature review of 121 articles, we assessed the frequency and variety of causation of this infrequent entity. The main finding was that by far the most common diagnosis causing SPE is amyloidosis and neoplasm, most notably neuroblastoma. Amyloidosis accounted for 23% articles (28/121) and neuroblastoma for 17% articles (21/121). Overall, neoplastic processes accounted for 30% of the articles (36/121), raised intracranial pressure and vascular malformations for 19% of the articles (23/121), migraine and atypical headache for 7% of the articles (8/121), while iatrogenic accounted for 5% of the articles (6/121). Through exploration and appreciation of the pathophysiology, we hope to foster a greater understanding in the clinician to establish underlying etiology, from benign to life-threatening, when presented with SPE.

A man with panda eyes after a fall.

Most commonly caused by trauma, basal skull fractures present with a range of clinical signs. These include periorbital ecchymosis, as seen in this case, as well as rhinorrhea, otorrhoea and post-mastoid ecchymosis. Suspected cases must be managed with appropriate imaging and medical or surgical treatment as indicated.

Systemic Amyloidosis Caused by Monoclonal Immunoglobulins: Soft Tissue and Vascular Involvement.

Clinical features of soft tissue amyloid light-chain (AL) amyloidosis include macroglossia, arthropathy, muscle pseudohypertrophy, skin plaques, and carpal tunnel syndrome. Vascular manifestations of AL amyloid include periorbital ecchymosis, jaw or limb claudication, and even myocardial infarction caused by occlusion of small vessel coronary arteries. Some of these features, such as macroglossia, periorbital ecchymosis, and the so-called shoulder-pad sign, are pathognomonic for AL amyloidosis. These findings may be the initial presenting features of the disease, and the recognition of these red flag symptoms is very important for the diagnosis and early intervention on the underlying plasma cell disease.

Efficacy of tranexamic acid on side effects of rhinoplasty: A randomized double-blind study.

INTRODUCTION: The aim of this randomized double-blind study was to evaluate the efficacy of Tranexamic acid (TXA) on intraoperative bleeding, postoperative eyelid edema, and postoperative periorbital ecchymosis in rhinoplasty. MATERIALS AND METHODS: Sixty rhinoplasty patients who needed hump reduction and lateral osteotomy were included and then randomly assigned into two groups. In the intervention group (n = 30), 10 mg/kg of TXA was administered prior to the operation and in the control group, the patients were given 20 mL of normal saline. Intraoperative bleeding was evaluated by gravimetric method and pre and postoperative hemoglobin and hematocrit levels were determined. Eyelid edema and periorbital ecchymosis were evaluated using 0-4 points scoring system. Surgeon satisfaction was measured by asking questions of the surgeon. Data were analyzed by SPSS 20.0 (P < 0.05). RESULTS: In total, 10 participants were excluded from the research, and 50 patients were included in the study. Mean (SD) of intraoperative bleeding was 213 (65) mL and 254 (55) mL in the intervention and control group, respectively, based on the clinical methods (P = 0.013). Level of hemoglobin was 266.69 in the control group versus 241.25 in the TXA group, indicating that this effect on the intraoperative bleeding was not significant (P = 0.1). Hematocrit differences before and after operation were significant (P = 0.03) (247.06 mL in TXA vs. 279.2 mL in the control group). TXA had a statistically significant effect on the eyelid edema (P = 0.03), periorbital ecchymosis (P = 0.04), and surgeon satisfaction (P = 0.03). CONCLUSION: Administration of 10 mm/kg TXA had a significant effect in decreasing the intraoperative bleeding rate, eyelid edema, and periorbital ecchymosis in the rhinoplasty with minimal side effects.

The clinical features of periorbital ecchymosis in a series of trauma patients.

INTRODUCTION: Periorbital ecchymosis (PE) is caused by blood tracking along tissue plains into periorbital tissues, causing discoloration in the upper and lower eyelids. This clinical feature is most commonly associated with basal skull fractures. Our objective is to present the first patient series describing the clinical features associated with traumatically induced PE. METHODS: The authors retrospectively reviewed 36 consecutive cases of patients presenting to the emergency department with PE over a three-year period at St. Michael's Hospital in Toronto. Data were obtained using a standardised data acquisition template. RESULTS: All patients presented to the emergency department with PE. The mean age in our series was 39 years (range 19-88 years), 31 patients were male. PE was associated with a variety of injuries including: 15 basal skull fractures, 9 soft tissue injuries without fractures, 8 convexity fractures, and 3 facial fractures. The other classic signs of basal skull fracture (Battle's sign, hemotympanum, cerebrospinal fluid otorrhea, cerebrospinal fluid rhinorrhea) were observed in 3, 7, 1, and 3 patients with PE, respectively. The most common clinical feature associated with PE was cranial nerve injury, observed in 10 patients. Surgical intervention was required in 8 patients. Five patients were discharged to a rehabilitation centre. No meningitis, cerebral abscess, encephalitis or deaths were observed. CONCLUSION: Periorbital ecchymosis is a useful clinic sign that should alert the clinician to assess for skull fractures, intracranial haemorrhage, and cranial nerve injury. However, this series shows that PE can be associated with a variety of clinical features, is rarely accompanied by other classic signs of basal skull fracture, and most patients with PE do not have injuries severe enough to require surgical intervention or post-discharge rehabilitation.

Panda sign due to severe coughing.

We present the case of a patient who developed periorbital ecchymosis (panda sign) following an exacerbation of asthma with severe coughing. There was no history of cranial trauma. Investigations for a structural or haematological cause were negative. The panda sign is typically seen following a base of skull fracture, but rarely reported due to severe coughing.