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Subperiosteal haematomas of the orbit are an uncommon cause of proptosis after trauma. Complications include diplopia, persisting mass, and compressive optic neuropathy. Treatment options include observation, needle aspiration, and surgical evacuation. In symptomatic patients without indications for orbital exploration, treatment with needle aspiration is less invasive than surgical drainage. We report a case of a traumatic subperiosteal haematoma successfully treated with needle aspiration, demonstrating that in appropriate patients, needle aspiration can result in resolution of symptoms without a more invasive procedure.
Case report
A 9 year old girl presented with diplopia 4 days after falling off a fence and striking the right side of her face. She denied decreased visual acuity, eye pain, or previous history of diplopia or proptosis. Her past medical and ocular histories were unremarkable.
On examination, her visual acuity was 6/6 in both eyes. Pupils were equal and reactive with no afferent pupillary defect. Intraocular pressure was normal in both eyes. Her right eye was displaced inferotemporally, and Hertel exophthalmometry showed 3 mm of proptosis of the right eye. The right eye was restricted in upgaze. External examination of the left eye, anterior segment examination of both eyes, and fundus examination of both eyes were normal.
Computed tomography (CT) of the orbits revealed an oval mass along the roof of the right orbit measuring 3.1 cm × 1.1 cm (Fig 1⇓) with no bone discontinuity or fracture. Clinical history and CT were consistent with the diagnosis of subperiosteal haematoma. The patient was observed, and on follow up examination a week later she described increasing diplopia. Her eye continued to be displaced (Fig 2A⇓), and there was restriction in upgaze, medial gaze, and lateral gaze. Treatment was recommended because of progression.
CT scan demonstrates a well circumscribed mass in the right superior orbit.
(A) Preoperative photograph shows proptosis and inferotemporal displacement of the right eye. (B) One week postoperative photograph demonstrates resolution of proptosis and displacement.
Drainage of the haematoma was performed by needle aspiration.1,2 With the patient under general anaesthesia, a 22 gauge, 1.5 inch needle on a syringe was advanced transcutaneously into the superior orbit lateral to the superior orbital notch until blood appeared in the syringe; 7 ml of dark red blood returned. The proptosis immediately resolved. On the first postoperative day, she had no proptosis or diplopia. Visual acuity was 6/6, and extraocular movements were full. She remained asymptomatic with a normal examination (Fig 2B⇑) at the 6 month follow up visit.
Comment
Orbital subperiosteal haemorrhages are rare, resulting from rupture of subperiosteal vessels or extension of subgaleal haematomas.2,3 Haematomas develop acutely or within days of orbital trauma. Clinical findings include acute proptosis, limitation of motility, and compressive optic neuropathy.2 Chronic complications may occur from infection, expansion, strabismus, choroidal folds, or persisting mass.1 CT demonstrated a well defined, extraconal, blood dense mass adjacent to an orbital wall. Magnetic resonance imaging identified stages of blood degradation and differentiated blood from neoplasms. Differential diagnosis includes subperiosteal abscess, rhabdomyosarcoma, orbital pseudotumour, lymphangioma, carotid cavernous fistula, arteriovenous malformation, orbital haematoma, or frontal sinus mucocele.
Management options include observation, needle aspiration, and surgical evacuation. Small haemorrhages without decreased vision may be observed for spontaneous resolution. Intervention is recommended for compressive optic neuropathy, progressive proptosis, suspicion of a tumour, or rebleed.3 Drainage has been performed successfully through needle aspiration1,2 and surgical evacuation.4 Needle aspiration is less invasive, but does not remove clots or stop active bleeding. Orbital exploration allows removal of coagulated blood, drain placement, and fracture repair. In a review of 11 cases in the literature, six patients underwent needle aspiration, four patients underwent surgical evacuation, and one case spontaneously resolved after 6 months.3
Subperiosteal haematoma of the orbit must be considered in the differential diagnosis of unilateral proptosis after trauma. Haematomas can be observed when vision is not threatened. However, early intervention can hasten the resolution of symptoms and prevent chronic complications. Needle aspiration in appropriate cases is a successful and minimally invasive method of treatment.