A 42-year-old male got admitted with COVID-19 related acute respiratory distress syndrome (ARDS). A Portex 7.5 French triple lumen catheter was placed in the right subclavian vein and trachea was intubated using a 7.5 mm endotracheal tube Rusch. On administering high positive end expiratory pressure ventilation, he developed subcutaneous emphysema over chest which progressed to the right side of his face involving the right orbit [Fig. 1a]. On examination, palpable crepitus was noted in the periocular region with subconjunctival collection of air [Fig. 1b]. Direct and consensual pupillary reflexes were normal. Bilateral intercostal drainage tubes were placed [Fig. 1c]. The emphysema spontaneously resolved in the following 2 days.
Orbital emphysema usually occurs after trauma and resolve spontaneously. They are of three types: Palpebral, True, and Orbito-palpebral. However, spontaneous orbital emphysema in COVID-19 ARDS has also been reported. Subcutaneous emphysema of thorax develops from pneumothorax barotrauma in a mechanically ventilated patient, and then air migrates to the orbit. Unilaterality in this case is because the patient was lying on a left lateral position.
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