Surgical management of periorbital non-traumatic subcutaneous emphysema during continuous positive airway pressure

A 47-year-old male requested treatment for recurrent, rapid left upper eyelid swelling due to subcutaneous emphysema (SE) with use of continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnoea. There was no previous history of facial trauma or surgery. Computerised tomography revealed pneumatisation of the lacrimal sac fossa and nasolacrimal duct with a prominent agger nasi air cell medial to the lacrimal sac extending down the nasolacrimal duct. He underwent endoscopic surgery to reduce the pneumatisation superomedial to the lacrimal sac. The subcutaneous emphysema significantly improved, only now occurring with very high CPAP pressure. Periorbital and orbital emphysema are typically secondary to trauma or iatrogenic causes. To the best of our knowledge, only one case of periorbital, non-traumatic emphysema secondary to CPAP has been reported. This is the first case to describe surgical reduction of a pneumatised lacrimal sac fossa to successfully treat CPAP-related non-traumatic subcutaneous emphysema.