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Periorbital Ecchymosis

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Periorbital ecchymosis can be defined as the condition in which dark circles surround the eyes. As you will have the opportunity to discover below, this condition can have different types of causes, the most common one being represented by the basal skull fracture. In the medical field, periorbital ecchymosis is also presented as panda or raccoon eyes, due to the obvious resemblance. If the condition was caused by a basal skull fracture, the patients are advised against coughing, sneezing or straining, as this can aggravate the condition (further tearing of the meninges). The periorbital ecchymosis forms as the blood from the skull fracture infiltrates into the soft tissues around the eyes.

Symptoms

These are the symptoms associated with periorbital ecchymosis:

  • Battle’s sign – this is also an ecchymosis, appearing behind the ear
  • Both ecchymosis appear several days after the injury
  • The ecchymosis can be unilateral or bilateral, the discoloration affecting both the upper and lower eyelids
  • Swelling can also be present as a symptom
  • Associated subconjunctival hemorrhage can be present in the situation that the periorbital ecchymosis is caused by blunt trauma
  • In case of neuroblastoma, the following symptoms might also be present:
    • Failure to thrive
    • Dysconjugate gaze (the sclera of the eyes remains normal)
    • The pupils are fixed and dilated
    • Abdominal mass present
    • Other changes include: subconjunctival hemorrhage, strabismus, bone pain
  • Superficial or subcutaneous hemangioma
  • In case of lymphangioma:
    • Vascular mass – present at the level of the orbit, eyelid or conjunctiva
    • Acute proptosis (usually triggered by an infection at the level of the upper respiratory tract)
  • In case of rhabdomyosarcoma:
    • Palpable mass
    • Periocular edema
    • Ptosis
    • Proptosis
    • Chemosis
  • Leukemia:
    • Retinal hemorrhage
  • Aplastic anemia:
    • Fatigue
    • Pallor of the skin
    • Recurrent infections
    • Mucosal hemorrhage
    • Menorrhagia
    • Petechiae
  • Thrombocytopenia:
    • Purpura
    • Petechial rash
    • Mucosal bleeding
    • Infection
    • Epistaxis
    • Gastrointestinal bleeding
  • Orbital myositis:
    • Diplopia
    • Painful proptosis
    • Ptosis
  • Amyloidosis:
    • Periocular pain
    • Palpable mass
    • Ptosis
    • Proptosis
  • Pertussis:
    • Coughing
    • Post-tussive vomiting
  • Blue rubber bleb nevus syndrome
    • Proptosis
    • Subconjunctival hemorrhage
    • Cutaneous lesions (blue rubber blebs)
    • Gastrointestinal bleeding.

Causes

These are the most common causes that can lead to the appearance of periorbital ecchymosis:

  • Basal skull fracture – leads to bilateral involvement (most common associated with fractures of the anterior cranial fossa)
  • Craniotomy (leading to the rupturing of the meninges)
  • Cancer (rare cases)
    • Disseminated neuroblastoma (commonly encountered in pediatric patients) – in neuroblastoma, the periorbital ecchymosis appears as the palpebral vessels are obstructed by tumor tissue, around the orbit area. The diagnosis of this condition is often delayed, due to it being mistaken for blunt trauma or physical abuse.
    • Amyloidosis (multiple myeloma)
    • Rhabdomyosarcoma
    • Leukemia
  • Hematologic disorders
    • Aplastic anemia
    • Thrombocytopenia
  • Benign vascular malformations (these can lead to spontaneous periorbital ecchymosis in children, requiring constant monitoring, so as to prevent potential visual complications)
    • Capillary hemangiomas
    • Orbital varices
    • Lymphangiomas
  • Blunt trauma to the eye due to falling, car accidents or physical force (for example, a fist), including perforating injuries
  • Intracranial hemorrhage
  • Cranial nerve injury
  • Orbital tumors
  • Giant cell arteritis
  • Orbital myositis
  • Pertussis
  • Blue rubber bleb nevus syndrome
  • Surgical intervention at the level of the ear (the periorbital ecchymosis appears as a complication of this intervention)
  • Fracture of the facial bones
  • Rhinoplasty
  • Endoscopic sinus surgery
  • Sinusitis
  • Superficial eyelid cellulitis
  • Preseptal infections
  • Allergic reactions.

Treatment

The periorbital ecchymosis can represent a medical emergency, especially if there is a suspicion of a basal skull fracture. Below, you will find the most common methods of treatment, according to the level of emergency and the seriousness of the condition that has caused the periorbital ecchymosis in the first place:

  • Surgical intervention
    • Recommended in patients who have suffered a basilar skull fracture or in those who have underwent craniotomy, suffering from a rupture of the meninges
  • Medical treatment
    • Indicated in patients diagnosed with cancer (neuroblastoma, amyloidosis)

This is the treatment according to each cause:

  • Capillary hemangioma:
    • Surgical intervention
    • Pulsed-dye laser
    • Steroids
    • Beta blockers
  • Lymphangioma:
    • Surgical debulking
    • Radiotherapy (local)
    • Intralesional sclerotherapy
  • Orbital varices:
    • Surgical debulking
    • Endovascular catheterization
  • Neuroblastoma:
    • Chemotherapy
    • Tumor resection
    • Stem cell therapy
  • Rhabdomyosarcoma:
    • Surgical debulking
    • Radiation therapy
    • Chemotherapy (systemic)
  • Leukemia:
    • Radiation therapy (local)
    • Chemotherapy (systemic)
  • Aplastic anemia:
    • Surgical decompression (orbital hemorrhage)
    • Bone marrow transplantation
  • Thrombocytopenia:
    • Intravenous immunoglobulins
    • Platelet transfusions
  • Orbital myositis:
    • Systemic steroids
    • Radiotherapy
    • Immuno-modulatory drugs
    • Surgical debulking
  • Amyloidosis:
    • Debulking
    • Steroids
    • Stem cell transplantation
  • Pertussis:
    • Systemic antibiotics
    • Supportive care (complications related to breathing)
  • Blue rubber bleb nevus syndrome:
    • Surgical debulking (keratopathy)
    • Endoscopic removal (GI bleeding)

In conclusion, periorbital ecchymosis often appears as the sign of an underlying condition. In the majority of the cases, it is caused by a fracture at the base of the skull and the patient has to be educated to avoid actions such as sneezing or coughing. The reason is that the force resulting from these actions could lead to the further tearing of the meninges, thus aggravating the condition.

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There are also patients who suffer from different types of rare cancer who present raccoon eyes. These rare cancers are especially encountered in children and the diagnosis is often delayed, as it is mistaken with physical abuse or trauma. However, if the parents present to the emergency rooms, with the child having raccoon eyes and other related symptoms but no history of recent trauma, the diagnosis has to be guided towards cancer. The sooner the treatment options are analyzed, the better the prognosis will be.

Also, it is essential to understand that this condition does not appear on its own. It is a sign that somewhere a hemorrhage has occurred or that the tumor tissue is obstructing certain vessels, causing them to break. The surgical intervention might be the only alternative to solving the immediate hemorrhage.

Pictures

Here is how Periorbital Ecchymosis looks like…
periorbital ecchymosis

periorbital ecchymosis pictures

periorbital ecchymosis pictures 2


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