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CHAPTER 3: Upper Facial Trauma

Resident Manual of Trauma to the Face, Head, and Neck

h. Periorbital Ecchymosis

Periorbital ecchymosis (“raccoon eyes”) is a common indicator of

ruptured blood vessels—usually the ethmoid arteries and/or the

angular artery and vein near the medial canthus (Figure 3.18). It can

also be suggestive of a basilar skull fracture, which must be ruled out

through diagnostic imaging.

Figure 3.18

Bilateral periorbital ecchymoses.

i. Retrobulbar Hematoma

Retrobulbar hematoma is a very serious condition, in which periglobal

blood vessels have been ruptured and blood accumulates around or

within the muscular cone. The patient will complain of pain, decreasing

vision, and pressure, and may have nausea and vomiting. There will be

obvious proptosis and a firm globe to gentle palpation, compared to the

normal side.

This is a true emergency. Ophthalmologic consultation is mandatory.

However, owing to the laxity that generally occurs with a lateral splay-

ing of the medial canthal tendons, there is a natural release to the

intraorbital pressure caused by the expanding hematoma. Nevertheless,

this will not last long, and intervention should be undertaken as soon as

diagnosed.

j. Epiphora

Epiphora is usually due to tissue edema surrounding the medial eyelids.

However, fractures and soft tissue injuries involving the lacrimal