Spontaneous facial subcutaneous emphysema.

Abstract

Patients with spontaneous pneumomediastinum present with various manifestations, but it is extremely rare for head and neck signs to be the sole presenting feature. In fact, out search of the literature found only 1 previously documented case of spontaneous facial subcutaneous emphysema of the head and neck. In this article, we report what to the best of our knowledge is the second such case--and the first in which pneumomediastinum manifested as an isolated cheek swelling.

Introduction

Facial subcutaneous emphysema is an uncommon condition. It arises in only a few sites, the most common of which is the mediastinum. Air from the mediastinum can easily ascend along fascial planes and into the subcutaneous spaces of the head and neck.

Most cases of pneumomediastinum are caused by surgery or trauma to the airway or upper gastrointestinal tract. Spontaneous pneumomediastinum is rare, occurring once in every 7,000 to 12,000 hospital admissions. It is much more common among patients with idiopathic pulmonary fibrosis who present to the hospital (5 to 15% of cases). (2,3)

While presentations of pneumomediastinum vary, we found only 1 previously documented case in which the patient initially presented with an isolated painless swelling above the neck. (4) We report what to the best of our knowledge is the first documented case of pneumomediastinum presenting as an isolated swelling of the cheek.

Case report

An 80-year-old man presented to the emergency department of a community hospital with a 1-day history of right cheek swelling without pain or erythema. The day before, he had been seen by his hearing aid dispenser, who had debrided his right ear and caused mild discomfort while doing so. The patient reported that although his hearing was unchanged and he had no otalgia or otorrhea, he did hear crackling in that ear. He believed that the swelling had started around the right ear and spread toward the middle of his face.

A chest x-ray performed in the emergency department was normal. The patient was treated with cefuroxime and referred to a community otolaryngologist. The otolaryngologist could find nothing wrong with the ear.

Over the next several days, the swelling increased, crossing the midline and involving the other cheek, as well as the neck, bilaterally. The worst swelling was centered over the right eyelid. The patient was then referred to the otolaryngology clinic of a tertiary care hospital. At that point, he was in no distress and he was experiencing no shortness of breath or chest discomfort. His history was significant for idiopathic pulmonary fibrosis, atrial fibrillation, and prostate cancer. His current medications included prednisone, azathioprine, furosemide, digoxin, warfarin, ateuolol, atorvastatin, and co-trimoxazole. He was a nonsmoker and used alcohol moderately.

Examination revealed the presence of subcutaneous emphysema over the right side of the face that extended toward the left side and down the neck bilaterally (figure 1). Subtle crepitus was palpable to the nipples bilaterally. The skin over the head and neck was otherwise normal in appearance. The external auditory canals and eardrums were intact, and the nose was clear anteriorly. The oropharynx was normal, but the right buccal mucosa bulged and was crepitant. Because there was no obvious source of the emphysema in the head and neck, another chest x-ray was ordered; this time, x-ray demonstrated a radiolucent line along the cardiac border, soft-tissue emphysema in the neck. and a reticular nodular pattern in the lungs consistent with the known pulmonary fibrosis. A working diagnosis of pneumomediastinum was made.

[FIGURE 1 OMITTED]

The pulmonology service was consulted, and a pulmonologist admitted the patient for observation. Computed tomography (CT) of the chest confirmed pneumomediastinum (figure 2). No evidence of pneumothorax or pleural effusion was seen. Pulmonary reticulations and some bullae were observed, but their appearance was unchanged when compared with imaging performed 1 year earlier.

[FIGURE 2 OMITTED]

Salbutamol and ipratropium inhalers were added to the patient's regimen, and he was discharged home after 2 days. The emphysema gradually resolved.

Discussion

Cervicofacial subcutaneous emphysema has only a few etiologies. It can occur as a direct result of facial, oral, or nasal mucosal trauma, including iatrogenic trauma secondary to dental surgery, sinus surgery, or adenotonsillectomy. Less often, it occurs following tracheal intubation or fiberoptic laryngoscopy. In rare cases, it has occurred as a result of an infectious process in the subcutaneous space, such as a retropharyngeal abscess?

In most cases, cervicofacial subcutaneous emphysema occurs when air ascends from a pneumomediastinum in one of three ways: as a result of (1) dissection along fascial planes from either the neck or retroperitoneum, (2) perforation of the trachea, bronchus, or esophagus, or (3) alveolar rupture and the migration of air through the interstitium. The last of these is the usual etiology of spontaneous pneumomediastinum.

Only in very rare cases does a patient with cervicofacial subcutaneous emphysema present with no signs or symptoms of pneumomediastinum and without any history of facial trauma, iatrogenic or otherwise. Patients with subcutaneous facial emphysema typically present with swelling and crepitus over the affected areas. This condition is almost always found simultaneously with cervical emphysema. The spectrum of pneumomediastinum presentation ranges from no symptoms to respiratory distress. The most common symptoms are a stabbing retrosternal chest pain, dyspnea, and cough. (2) Other complaints include neck pain, dysphagia, and sore throat. The classic sign of pneumomediastinum is Hamman's sign, a crunching sound over the precordium that is synchronous with ventricular systole. Other findings may include subcutaneous emphysema in the suprasternal and supraclavicular areas and a decrease in cardiac dullness to percussion.

Complications of cervicofacial emphysema are uncommon and site-dependent. Airway obstruction can be life-threatening, and it is seen with massive or retropharyngeal air infiltration. If subcutaneous emphysema affects the eustachian tube or palatal muscles, middle ear effusions can occur. Orbital involvement may cause a loss of vision secondary to pressure effects. Infection of air-filled sites is possible, especially if the port of entry is unclean, as in the case of an open facial fracture. The complications of pneumomediastinum include cardiac tamponade, airway obstruction, pneumothorax, mediastinitis, and deep neck infection.

While CT is considered the diagnostic standard, x-ray is still the most common means of diagnosing mediastinal and subcutaneous emphysema, even in patients with idiopathic pulmonary fibrosis. (2) Both imaging modalities will show gas outlining mediastinal structures and air streaking in the chest wall or neck. In the presence of a positive physical examination and radiography showing mediastinal emphysema, no further investigations are necessary to diagnose facial subcutaneous emphysema. If complications of facial subcutaneous emphysema are suspected, a head and neck CT is indicated.

Management of facial subcutaneous emphysema usually involves hospital admission and observation for complications. If facial trauma is the cause, fracture reduction and closure of lacerations are required. With mediastinal emphysema, further transmission of air up fascial planes can be reduced by eliminating straining and increasing intrathoracic pressure with cough suppressants, stool softeners, analgesics, and bed rest. Treatment of pneumomediastinum is also conservative, but most experts advocate giving 100% oxygen to increase the rate of gas resorption. Antibiotic prophylaxis may reduce the incidence of mediastinitis and deep neck abscess. In uncomplicated cases, the emphysema will spontaneously resolve over 1 to 2 weeks.

References

(1.) Halperin AK, Deichmann RE. Spontaneous pneumomediastinum: A report of 10 cases and review of the literature. N C Med J 1985:46:21-3.

(2.) Franquet T, Gimenez A, Torrubia S, et al. Spontaneous pneumothorax and pneumomediastinum in IPF. Eur Radiol 2000:10:108-13.

(3.) Fujiwara T. Pneumomediastinum in pulmonary fibrosis. Detection by computed tomography. Chest 1993:104:44-6.

(4.) Shah SI. Applebaum EL. Spontaneous subcutaneous temporal emphysema, Am J Otolaryngol 2000:21:337-9.

(5.) Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984:144:1447-53.

Kevin Ramchandar, MD; Michele M. Carr, DDS, MD

From the Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pa.

Reprint requests: Michele M. Carr, DDS, Otolaryngology-Head and Neck Surgery, H091, Milton S. Hershey Medical Center, Pennsylvania State University, 500 University Dr., P.O. Box 850, Hershey, PA 17033-0850. Phone: [phone]; fax: [phone]; e-mail: [e-mail]