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258
CHAP TER9 The cheek andorbit
Common presentations
Some common periorbital problems:
• Doublevision
• Infections
• Injuries
• Pain (see also E Chapter 10)
• Proptosis
• Swelling.
Common problems and theircauses
Doublevision
Common
• Alcohol intoxication
• Fractures to the zygoma/ orbit
• CN III, IV, VIinjury
• Orbital swelling/ bruising.
Uncommon
• Fractures to the NOE/ skull
• Orbital myositis
• Tumours
• Migraine
• Neurological disease(MS)
• Sinusitis
• Orbital abscess
• Graves’ disease
• Strabismus
• Globe disorders.
Infections
Common
• Eyelid infections (see E Chapter 10)
• Skin infections
• Dental infections
• Sinusitis.
Uncommon
• Orbital cellulitis.
Injuries
Common
• Fractures (zygoma or isolated orbital)
• Lacerations (eyebrows, eyelids)
• Foreign body injuries.
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
Uncommon
• Chemical injury to eyes (see E Chapter 10)
• Penetrating eye injuries (see E Chapter 10).
Pain
(See also E Chapter 10.)
Common
• Trau m a
• Eyelid/ sinus infections
• Migraine/ cluster headaches
• Eye strain.
Uncommon
• Orbital cellulitis
• Tumour/ pseudotumour
• Thyroid eye disease
• Temporal arteritis
• Herpes zoster.
Proptosis and swelling
Common
• Trau m a
• Eyelid/ sinus infections
• Thyroid eye disease
• High myopia (short- sightedness).
Uncommon
• Retrobulbar haemorrhage(RBH)
• Tumour
• Orbital cellulitis
• Orbital inammatory disease
• Dermoid/ epidermoid cysts/ haemangioma
• Carotid cavernous stula.
259
Useful questions and what
tolookfor
Doublevision
Askabout
• Onset
• Static or progression
• One or botheyes
• Diplopia looking in one direction or all directions
• Recentinjur y
260
CHAP TER9 The cheek andorbit
• Is the double vision wor se at the end of the day or whentired?
• Any deterioration invision
• Any other symptoms (swelling/ headaches).
Lookfor
• Obvioussquint
• Signs ofinjur y
• Proptosis
• Numbness of cheek and forehead (and CN examination)
• Examine the eye/ eye movements.
Infections
Askabout
• Duration/ previous episodes
• Recent skin infections ortrauma
• Pain, erythema, and swelling
• Changes in visual eld, blurred vision, diplopia
• Systemic symptoms
• Impaired mentalstatus
• Dischar ge from noseoreye
• Headaches
• Medicationstaken.
Lookfor
• Site and extension (conned to eyelids or spreading into
surrounding tissues)
• Skin erythema swelling and any uctuant swelling
• Systemic involvement (pyrexia, sweating, lethargy)
• Assess cranialner ves
• Assess the eye (see E Chapter 10)
• Numbness of the cheek and forehead.
Injuries
Askabout
• Mechanism ofinjury
• Any other injur ies
• Possibility of foreignbody
• Associated neurological decit— numbness or change in vision,
visual eld, diplopia
• Pain and discharge from eye orwounds
• Alcohol or medicationstaken
• Chemical exposure toeye.
Lookfor
• Assess GCS/ C- spine
• Assess visualacuit y
• Lacerations or foreignbodies
USEF UL QU ESTI ONS AND WHAT TO LOOKFOR
• Assess bones of orbit, maxilla, forehead, and mandible
• Intercanthal distance>40mm
• Assess eye movements in all directions/ diplopia
• Assess cranialner ves
• Numbness of cheek and forehead.
Pain
Askabout
• Onset
• Static or progression
• Recentinjur y
• Pain in the eye, behind the eye, or around theeye
• Headache and associated symptoms
• Photophobia
• Blurred vision/ diplopia.
Lookfor
• Assess visualacuit y
• Eye movements/ diplopia
• Signs ofinjur y
• Signs of infection
• Proptosis
• Numbness of cheek and forehead
• Neck stiness/ photophobia
• Tenderness in the temple (temporal arteritis).
Proptosis and swelling
Askabout
• Recent skin/ upper dental infections or facialtrauma
• Duration— hours, days, orweeks
• One vs bothsides
• Painful/ painless
• Change in vision/ ocular symptoms
• Systemic symptoms
• Headaches.
Lookfor
• Assess visualacuit y
• Eye movements/ diplopia
• Signs ofinjur y
• Is swelling around the orbit or behind theeye?
• Is proptosis pulsatile?
• Numbness of cheek and forehead
• Systemic involvement (pyrexia/ malaise/ thyroid status).
261
262
CHAP TER9 The cheek andorbit
Examination ofthe cheek andorbit
Examination of the cheek and orbit is not complete without an examination
of the eye itself. This latter part of the examination is discussed in detail in
Chapter 10 on the eye but is noted brieyhere.
Applied anatomy
Thecheek
The ‘cheek bone’ is formed predominantly by the z ygomatic bone. This
has a superior process, which fuses with the frontal bone at the frontozygomatic suture just at the lateral aspect of the eyebrow. This is a
key site in examination; tenderness and step deformity suggest a fracture
of the cheek. Medially, the zygoma joins with the maxilla approximately
two- thirds of the way along the infraorbital rim. This provides support
for the lower eyelid. Lower down anteriorly, the cheek bone fuses with
the anterior wall of the ma xilla, passing medially to form the piriform
(nasal) aper ture. The lower lateral aspect of this bony complex (often
referred to as the ‘buttresses’) can be palpated from within the mouth,
just above the roots of the upper premolar and molar teeth. Te nd ern ess
and step deformity of this buttress suggest a fracture of the cheek. Bruising
may also be visible.
The body of the zygoma forms the prominence of the cheek. Together
with the supraorbital ridge it provides a degree of protection to the
globe. The bones in this region also provide suppor t to the soft tissues,
notably the lower eyelid and the medial and lateral canthal tendons.
Displacement of the bones results in obvious asymmetry and a vertical
drop in the position of the lateral canthus, sometimes termed an ‘antimongoloid slant’. There may also be hypoglobus. The z ygomatic arch is a
key ‘strut’ in maintaining the forward projection of the cheek. Its importance can be overlooked when assessing facial X- rays.
Theorbit
This is a pyramidal- shaped str ucture enclosed by four bony walls— the
roof, oor, medial, and lateral walls. These converge at the orbital apex.
The globe is a round ball approximately 24mm in diameter which occupies only about a quarter of the orbital volume. The remainder is made
up of the lacrimal apparatus, muscles, fat, blood vessels, and nerves. The
cornea of the globe is bathed in tears which originate from the lacr imal
gland (upper lateral aspect of the orbit) and pass across the cornea in a
medial direction towards the punctae. From there they pass through the
canaliculi and lacrimal sac, which sit s in a bony recess, the lacrimal fossa,
before passing into thenose.
The walls of the orbit are of varying thickness and strengths. The
medial orbital wall is particularly thin and perforated by numerous valveless blood vessels and ner ves through a number of defect s (Zuckerk andl
dehiscences). This allows for easy communication of infectious material
between the ethmoidal air cells and orbital soft tissues. The vessels here
can bleed profusely into the orbit following trauma, which can result
in a retrobulbar haematoma. Sensation to the cheek and lateral nose
comes from the infraorbital nerve which passes along the orbital oor.
Sensation to the forehead is from the supraorbital and supratrochlear
EX AMIN ATION OF THE CHEEK ANDOR BIT
nerves, both arising from the ophthalmic division of the trigeminal nerve.
All these nerves are at risk of injury following either trauma to the orbit
or from other intra- orbital pathology.
The upper par t of the orbit is also part of the frontal bone. Signicant
force is required to fracture this bone. Injuries to this area may therefore
be associated with dural tears, CSF leakage, and brain or cervical injury. The
lateral wall of the orbit is composed of the zygoma and greater wing of
the sphenoid (par t of the middle cranial fossa). The most common injury
in this region is fracture of the zygomaticbone.
Where the infra- orbital ner ve passes along the oor of the orbit, the
bone is especially weak. Isolated fractures of the orbital oor, or those
associated with fractures of the zygoma , usually pass along this canal.
Numbness of the cheek and upper lip is therefore an important sign that
could indicate an underlying fracture. Occasionally the orbital contents
herniate out following fracture of the orbital oor or medial wall. This
is mostly periorbital fat but occasionally the extr aocular muscles herniate. Entrapment prevents the coordinated action of the ocular muscles
and may result in restricted eye movements and double vision (diplopia).
There are six striated muscles responsible for moving the eye:the four
recti muscles (medial, lateral, superior, and inferior) and the superior
and inferior oblique muscles. The nerves supplying these are the oculomotor, trochlear, and abducens nerves— ‘SO4(LR6)3’ indicates the
individual muscle innervations. The recti muscles have a common point
of origin along the tendinous ring at the orbital apex. From there they
pass forwards forming a muscular cone before inserting into the sclera.
This cone can ac t as a closed compartment and contain blood following
surgery or trauma(RB H).
The optic ner ve runs from the back of the globe to the orbital apex and
enters the cranial cavity via the optic foramen. Running in the opposite
direction within this foramen is the ophthalmic arter y which is a branch
of internal carotid arter y. The remaining blood vessels and nerves to the
orbital content s gain access to the orbit via the superior orbital ssure.
Anteriorly the orbit is enclosed and protected by the eyelids. The
upper eyelid is the most mobile and is elevated by the combined ac tions
of a smooth muscle and a striated muscle (Müller’s muscle and levator
palpebrae super ioris respectively). The orbital septum is a layer of fascia
extending vertically from the peripheral periosteum of the orbital rim
into the levator aponeurosis in the upper eyelid and the inferior border
of the tarsal plate in the lower eyelid. This is important as infection that
passes deep to the septum can enter the orbit, resulting in orbital cellulitis. Eyelid and periorbital swellings therefore require prompt diagnosis and
management.
Examination
(See also E Chapter 10.) The face should be inspec ted from the front
and side of the patient. It should also be viewed from above, looking
down over the brow. With all orbital- related conditions, early assessment
of the eye is essential as management initially takes priority. If the eyelids
are closed due to painful swelling, gently pressing on the eyelids (not
the globe) for a few minutes can often reduce swelling suciently to
assess the eye. However, be careful if the swelling is thought to be due to
263
264
CHAP TER9 The cheek andorbit
cellulitis or an abscess. If necessar y, a Desmarres retractor, lid speculum,
or even a bent sterile paper clip can be used to gently retract the eyelids,
while avoiding pressure on the globe. If necessary, apply topical anaesthetic (either tetracaine or proparacaine drops) to decrease discomfort.
When there is signicant swelling, assessment of the eye can be limited.
As a minimum, make sure you assess visual acuity, pupils, extraocular
motility, and visual elds. Never allow a patient with orbital pathology to
go home if you have been unable to assess the eye. Inability to open the
eyelids is not an acceptable reason. If you cannot assess the eye, discuss with
opht halmology. Gross examination of the eyelids, conjunctiva, sclera, cor-
nea, and anterior chamber may reveal lacerations, anatomic disruption,
haemorrhage, or foreign bodies. Contact lenses and super cial foreign
bodies should also be removed. If a penetrating injury to the eye is sus-
pected, pressure should be avoided.
External examination
The eyelids and periocular region should be inspected, t aking note of
asymmetry, oedema, ecchymosis, lacerations, foreign bodies, or abnormal eyelid position. Any ‘black eye’ with a sharply dened border should be
regarded as a sign of an underlying fracture (Figure9.1).
Ptosis (drooping of the upper eyelid) is common following injury and
is typically the result of oedema. Other causes include third nerve palsy,
levator muscle injury, or tr aumatic Horner’s syndrome. Medial eyelid lacerations should r aise the suspicion of canalicular injury. The presence of
fatty tissue within a lid laceration indicates perforation of the orbital septum
and should raise suspicion for an orbital injury, globe injury, and a foreign
body. The orbital rims should be palpated for bony steps and tender-
ness. Any sensory loss in the cheek and forehead should be noted and
compared to the other side. Periorbit al surgical emphysema is highly suggestive of a fracture involving the cheek, orbit al oor, or medial orbital
wall. When the nose is blown, air normally contained within the sinuses
Zygoma
Zygoma
Figure9.1 Frac tures res ulting in a ‘blackeye’.
Skull base
Skull base
Blowout
Blowout
Nose
Nose
Nose
NOE
NOE
NOE
EX AMIN ATION OF THE CHEEK ANDOR BIT
escapes into the sof t tissue. It can also occur in some infections or any
erosive pathology that destroys bone. The intercanthal distance has a
wide range; in Caucasians, for example, it is about 28 – 35mm. Increased
intercanthal distance >40mm (approximately the width of the patient’s
eye) suggests displacement of the medial canthal tendon. These patients
require CT imaging (see E Chapter 7).
Visualacuity
This should be determined independently in each eye using a Snellen
char t, with the patient wearing their spectacles or using a pinhole.
Topical anaesthetics may help if the patient has acute pain or blepharospasm. If unable to visualize print, record counting ngers at a specied
distance, hand motion, light perception, or no perception.
Pupil examination
Pupil size and reactivity are impor tant determinants of globes status,
particularly in the unconscious. The size, shape, symmetr y, and reaction
to light should be noted. Patients should also be assessed for a relative
aerent pupillary defect (RAPD).
Globe position and ocular motility
The presence of proptosis and dystopia should be noted. This may indicate haemorrhage, infection, inammation, or tumour. Looking at the
orbits from above (bird’s- eye view) or below (worm’s- eye view) assists
in determining the degree of proptosis. Reection of light o the patient’s
corneas should be in the same position in both eyes. This means that the
globes are level and looking in the same direction. If one eye appears
lower than the other this is called hypoglobus, or ver tical ocular dystopia. This may be seen in zygomatic or orbital oor fractures, or spaceoccupying lesions or swellings. If the eye appears ‘sunken in’ this is likely
to be enophthalmos, indicating an orbital fracture. Be careful, the globe
may also appear sunken in if it is ruptured or is a prosthesis. Proptosis
(exophthalmos) is common, but usually mild following injury. Remember
non- traumatic causes aswell.
The patient should be able to painlessly move their eyes in all direc-
tions. Limited motility has many causes (notably fractures, muscle injury,
entrapment, cr anial ner ve injury, or orbit al oedema and blood). When
assessing eye movements, move the object slowly— otherwise subtle
restriction may be overlooked. Look closely a s they look up. If there is
entrapment the a xis of rotation shifts and sometimes the eye can be seen
to rotate into the orbit. This is called a ‘retractionsign’.
It is important to distinguish whether diplopia is monocular or bin-
ocular. Diplopia that persists when the opposite eye is covered is monocular
and suggests an abnormality of the globe, such as corneal irregularity, lens
abnormality or iridodialysis. Diplopia that resolves when covering either
eye is a defect in the coordinated eye movement. Diplopia on upward
gaze is a clinical sign of orbital oor entrapment whereas in downward
gaze it can be associated with dysfunction of the inferior rectus from
simple bruising.
265
266
CHAP TER9 The cheek andorbit
Visual eld testing
Visual eld testing can detect a number of disorders. Confrontational
(face- to- face) visual eld assessments are measured one eye at a time
and can be per formed by comparing the patient’s elds to the examiner’s own eld (assuming that the examiner has normal visual elds). At
a normal conversational distance, a t arget (e.g. ngers or cot ton- tipped
applicator s) can be placed at the per iphery of the visual eld equidistant
between the examiner and patient. Care must be taken to ensure that
the unexamined eye of the patient is completely covered.
Intraocular pressure measurement
Elevated intraocular pressure (IOP) can result from numerous conditions, including hyphaema, glaucoma, RBH, tumours, thyroid eye
disease, or carotid- cavernous stula. Decreased IOP can result from
open- globe injury, uveitis, cyclodialysis (separation of the ciliary body
from the sclera), or retinal detachment . IOP may be measured using
an applanation tonometer, portable Tono- Pen®, or Schiotz tonometer.
Topical anaesthesia (tetracaine) is necessary.
Useful investigations
See also E Chapter 10.
Laborator ytests
A FBC with dierential is usually required for any infective, inammatory,
systemic, or neoplastic pathologies.
The ESR should be taken when symptoms suggest the possibilit y of
temporal arteritis.
Plainlms
Occipitomental (15 and 30 degrees) and later al facial views are commonly required in the preliminar y assessment of zygomatic/ orbital and
some mid- face injuries. They are also of use in the preliminar y assessment of the maxillary and ethmoid sinuses.
Soft tissue views may be required to locate a foreignbody.
CT/ M RI
CT has largely replaced conventional plain lm radiography in the evaluation of periorbital trauma and other sinus/ orbital patholog y (tumours,
infections, etc.). CT is par ticularly useful in the evaluation of orbital fractures, intraocular and orbital foreign bodies, globe rupture, and spaceoccupying lesions. However, radiolucent foreign bodies such as plastic
or wood may be dicult to detect on CT or plain lm. Standard CT
examination should include both axial and coronal views. Sagittal views
are also very useful in the evaluation of orbital oor injuries. With today’s
modern scanner s all these views are now easily obt ained. Contrast is not
necessary in trauma, but may be for other pathologies, so the patient’s
U&Es may need to be checked. MRI is useful in the evaluation of suspected tumours or soft tissue abnormalities.
ORBITAL FRACTURES (ISOLATED)
Angiography
This may be required urgently following trauma (especially penetrating
injuries). If bleeding is active, selec tive embolization may be necessary.
Angiography is also occasionally undertaken in the assessment of vascular swellings (alternatively, CTA or MRA may be performed).
Ultrasound
This has a limited role, but can be of use in identif ying some ocular
pathologies or foreign bodies.
cOrbital fractures (isolated)
Orbital fractures can aect any of the orbital walls or orbital margin.
These may occur in isolation or be part of a larger fr acture complex, with
involvement of the surrounding bones (e.g. NOE, z ygomatic, anter ior
cranial fossa). The term ‘blowout’ fracture refers specically to an isolated
injury to one or more orbital walls (commonly the oor or medial wall) but
with the surrounding orbital rims intact. The orbital oor and medial orbital
wall are par ticularly delicate and are easily damaged, resulting in these
fractures. There are two proposed mechanisms. A direct blow to the
globe (e.g. squash ball to the eye) can result in the transfer of energy
directly to the or bital oor or medial wall. In these cases the globe can
also be seriously injured. Alternatively, a blow to the prominence of the
cheek, can deform the bone such that it ‘buckles’, resulting in fracture
propagation within the orbit. This type of fracture may be associated
with concurrent facial fractures to the z ygoma or midface.
Clinical features
• Swelling/ bruising/ tenderness (not specic)
• Diplopia (usually on looking up) (Figure9.2)
• Enophthalmos/ vertical ocular dystopia
• Proptosis may occur if there is a lot of swelling or surgical emphysema
• Numbness of thecheek
• Globe injury.
Investigations
• Occipitoment al and later al facial views (for associated cheek or mid-
facial injury) may suggest a ‘hanging drop’ sign. This may represent
the herniation of orbital contents into the maxillary sinus. However,
it may not be easily seen and not all ‘hanging drops’ are herniated
contents. Nevertheless, it is an important sign and merits further
investigation. Auid level in the sinus suggests there is a fracture
somewhere.
• Coronal/ axial CT of orbits.
• Orthoptic assessment— Hess char t, measurement of globe
projection and elds of binocular vision (to assess restriction of
ocular movement). Swelling may preclude immediate assessment.
267