Nontraumatic orbital roof blowout fracture following nose blowing: illustrative case

BACKGROUND Orbital blowout fractures generally involve the floor or medial wall and usually result from blunt trauma. Nontraumatic orbital roof fractures associated with nose blowing are exceptionally rare. OBSERVATIONS An 84-year-old man developed immediate left orbital swelling, epistaxis, diplopia, and impaired downgaze after forceful nose blowing. CT demonstrated fractures of the left medial orbital wall and orbital roof, with intracranial herniation of orbital tissue. MRI showed herniation of the superior rectus muscle and orbital fat through the roof defect and an adjacent inferior frontal lobe hematoma. During an extradural transcranial operation, herniated orbital fat was found to have penetrated the dura and adhered firmly to the frontal lobe. The adherent tissue was released, the dura and periorbita were repaired, and the orbital roof was reconstructed. Diplopia and downgaze limitation improved postoperatively. LESSONS An orbital roof fracture should be considered when orbital swelling and diplopia develop immediately after forceful nose blowing, even without trauma. Intracranial herniation and adhesion of orbital tissue may contribute to persistent ocular motility disturbance and may warrant surgical treatment. https://thejns.org/doi/abs/10.3171/CASE26847