Age: 67
Sex: Male
Indication: Head trauma
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Case #26
Findings
- Acute right medial orbital wall and orbital floor blowout fractures with herniation of orbital fat through the orbital floor fracture and enlargement and slight deviation of the inferior and medial rectus muscles
- Enlargement of the remaining right extraocular muscles with retrobulbar hemorrhage, emphysema, and right proptosis with taut appearance of the optic nerve. Stranding at the right optic nerve insertion site
- Acute fracture of the right frontal process of the maxilla extending posteriorly to involve the right nasolacrimal canal
- Acute mildly displaced fracture of the anterior and posterior walls of the right maxillary sinus with retroantral hemorrhage and gas
- Frank right lens dislocation with the lens positioned posteriorly in the globe
- Right maxillary and ethmoid hemosinus. Mucosal thickening of the left maxillary sinus and frontal sinuses with trace fluid layering in the right frontal sinus
- Extensive right periorbital soft tissue swelling
Diagnosis
- Right orbital blowout fractures
- Lens dislocation
- Concern for optic nerve injury
Sample Report
Acute right medial orbital wall and orbital floor blowout fractures with herniation of orbital fat through the orbital floor fracture and enlargement and slight deviation of the inferior and medial rectus muscles. Recommend correlation with clinical signs of entrapment.
Findings concerning for right optic nerve injury including retrobulbar hemorrhage and emphysema with proptosis, taut appearance of the optic nerve, and stranding at the optic nerve insertion site.
Acute fracture of the right frontal process of the maxilla extending posteriorly to involve the right nasolacrimal canal.
Acute mildly displaced fracture of the anterior and posterior walls of the right maxillary sinus with retroantral hemorrhage and gas.
Frank right lens dislocation with the lens positioned posteriorly in the globe. Globes appear intact.
Right maxillary and ethmoid hemosinus. Mucosal thickening of the left maxillary sinus and frontal sinuses with trace fluid layering in the right frontal sinus.
Extensive right periorbital soft tissue swelling.
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