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Orbital blowout fracture caused by nose blowing.


The occurrence of an orbital blowout fracture caused by nose blowingis an unusual phenomenon. We report a rare case of such a fracture in the bony floor of the orbit of a 30-year-old man. Immediately after strong nose blowing, he experienced left eyelid edema and diplopia. Computed tomography confirmed the presence of a blowout fracture of the inferior wall of the left orbit. His symptoms abated without any surgical treatment. In addition to the facts of this case, we discuss the findings of physiologic studies and human cadaver studies in the context of nose blowing as an etiologic factor in orbital blowout fracture.


Orbital blowout fractures are typically caused by blunt trauma to the orbit during sports activities, fights, traffic accidents, etc. We report a rare case of orbital blowout fracture of the inferior wall that was caused by nose blowing.

Case report

A 30-year-old man presented to our hospital with left eyelid edema and diplopia. The edema appeared immediately after the man had engaged in strong nose blowing earlier in the day; the diplopia appeared and slowly progressed thereafter. The patient had no significant personal or family history of nasal disease.

On examination of the nose, no bleeding or swelling of the nasal mucosa was noted. On ophthalmologic examination, globe mobility was slightly disturbed. Computed tomography (CT) detected a blowout fracture of the inferior wall of the left orbit (figure). CT demonstrated orbital and subcutaneous emphysema, as well as herniation of the orbital soft tissue into the maxillary sinus. No evidence of any entrapment of the inferior rectus muscle was seen.

The patient was treated with 450 mg/day of tosufloxacin for 5 days for prophylaxis against infection. His diplopia resolved 4 days after presentation, and his eyelid edema resolved 12 days after its onset.


To the best of our knowledge, only 3 cases of an orbital fracture induced by nose blowing have been previously reported in the literature. (1-3) In 1996, Oluwole and White reported the case of a woman who sustained an orbital blowout fracture of the inferior wall while nose blowing. In 2001, Suzuki et al described the case of a woman who experienced a blowout fracture of the medial wall of the right orbit along with orbital emphysema and herniation of the orbital soft tissue after vigorous nose blowing? In 2010, Rahmel et al presented the case of a 40-year-old man who required repair of a blowout fracture of the orbital floor as a result of vigorous nose blowing. (3) The mechanism of injury in orbital blowout fractures has long been an area of debate for otolaryngologists, ophthalmologists, and plastic surgeons. Most accepted explanations fit into one of two theories:

* The hydraulic theory holds that fractures of the thin orbital floor are brought about by hydraulic forces, which cause posterior globe displacement and increased orbital pressure. (4)

* The buckling theory implicates direct trauma to the inferior orbital rim, which causes the floor to buckle. (5)

Oluwole and White presumed that the fracture in their patient (a 70-year-old woman) occurred as the result of an increase in intranasal pressure, which led to a rupture of the orbital bone wall that had thinned with age. (1) Suzuki et al, whose patient was much younger (a 32-year-old woman), hypothesized that the thin orbital wall can be broken merely by the force of compressed air in the nasal cavity, regardless of the patient's age. (2) They speculated that the compressed air enters the orbit through the lacerated orbital wall and expands as it is released from pressure, resulting in the herniation of the orbital contents through the weakest site of the orbital wall. Their explanation supports the validity of the hydraulic theory. In view of the fact that our patient was only 30 years old, we agree with Suzuki et al. (2)


The question in our case was whether the elevation of the maxillary sinus pressure was sufficient to cause the blowout fracture. Not much is known about the pressure generated during nose blowing. Clement and Chovanova compared nasal resistance and pressures generated during normal breathing and nose blowing in patients with chronic sinusitis, in patients with septal deviations, and in normal controls. (6) They found that in the control group, the mean amount of pressure generated was 195.000 [+ or -] 90.894 daPa during right-sided nose blowing with the left nostril open and without decongestion, and 533.333 [+ or -] 183.143 daPa during right-sided nose blowing with both nostrils closed and without decongestion. The maximum pressure was 2,420 daPa, which indicated that nose blowing can generate extremely high pressures. Because energy is equivalent to pressure multiplied by volume, we estimated that the volume of the maxillary sinus in their control group was 35 ml, (7) and the energy loaded to the maxillary sinus by nose blowing with one nostril open was 68.250 [+ or -] 31.813 mJ. (6) The level of energy loaded into the maxillary sinus by nose blowing might be even higher with both nostrils closed or in patients with nasal complaints.

Several experimental studies have been conducted to assess the amount of energy required to fracture the bone of the orbital floor. Bullock et al measured the force by dropping a metal rod onto orbital floors obtained from human cadavers. (8) They also created biomathematical models of the human bony orbit as a thin-walled, truncated, conical shell and predicted the amount of energy required to fracture the bone using this model. Based on the hydraulic theory, they reported that the mean amount of predicted theoretical energy required to cause an orbital floor blowout fracture was 71 mJ (range: 38 to 127).

Rhee et al tested the hydraulic theory by impacting fresh, unfixed cadaver heads with a pendulum apparatus made of a 1-kg iron cylinder measuring 2.5 cm in diameter. (9) Specimens were aligned with the pendulum to ensure that only the globe would be impacted. Bony displacement with herniation of the orbital contents was obtained with the application of 4,900 mJ of energy.

Finally, Ahmad et al demonstrated that the average amount of energy required to fracture the orbital floor with a hydraulic mechanism was 1,220 mJ. (10) They used intact orbits of fresh human cadavers, and dropped a cylindrical mass of 232 g on the globe from various heights.

The amount of energy required to effect an orbital blowout fracture of the inferior wall differed in each of these cadaver studies. We believe that nose blowing can exert sufficient pressure to induce orbital blowout fracture.


(1.) Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75(3):169-70.

(2.) Suzuki H, Furukawa M, Takahashi E, Matsuura K. Barotraumatic blowout fracture of the orbit. Auris Nasus Larynx 2001;28(3):257-9.

(3.) Rahmel BB, Scott CR, Lynham AJ. Comminuted orbital blowout fracture after vigorous nose blowing that required repair. Br J Oral Maxillofac Surg 2010;48 (4):e21- 2.

(4.) Smith B, Regan WF Jr. Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957; 44(6):733-9.

(5.) Fujino T. Experimental "blow-out" fracture of the orbit. Plast Reconstr Surg 1974;54(1):81-2.

(6.) Clement P, Chovanova H. Pressures generated during nose blowing in patients with nasal complaints and normal test subjects. Rhinology 2003;41(3):152-8.

(7.) Emirzeoglu M, Sahin B, Bilgic S, et al. Volumetric evaluation of the paranasal sinuses in normal subjects using computer tomography images: A stereological study. Auris Nasus Larynx 2007;34(2):191-5.

(8.) Bullock JD, Warwar RE, Ballal DR, Ballal RD. Mechanisms of orbital floor fractures: A clinical, experimental, and theoretical study. Trans Am Ophthalmol Soc 1999;97:87-110; discussion 110-13.

(9.) Rhee JS, Kilde J, Yoganadan N, Pintar F. Orbital blowout fractures: Experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg 2002;4(2):98-101.

(10.) Ahmad F, Kirkpatrick NA, Lyne J, et al. Buckling and hydraulic mechanisms in orbital blowout fractures: Fact or fiction? J Craniofac Surg 2006;17(3):438-41.

Tetsuo Watanabe, MD, PhD; Toshiaki Kawano, MD; Satoru Kodama, MD, PhD; Masashi Suzuki, MD, PhD

From the Department of Otolaryngology-Head and Neck Surgery, Oita University Faculty of Medicine, Yufu City, Oita, Japan.

Corresponding author: Tetsuo Watanabe, MD, PhD, Department of Otolaryngology-Head and Nech Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu City, Oita 879-5593, Japan. Email:
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Author:Watanabe, Tetsuo; Kawano, Toshiaki; Kodama, Satoru; Suzuki, Masashi
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Jan 1, 2012
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