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A case of recurrent subcutaneous emphysema as a complication of endotracheal intubation.

Abstract

We describe a case of subcutaneous cervicofacial emphysema in a 21-year-old man who had undergone endotracheal intubation while under general anesthesia 2 months earlier The emphysema had arisen on the right side of the face and neck and extended to the right shoulder and the cubital fossa. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. On hospital day 10, he had improved sufficiently to warrant discharge on the next day. Two months later, the patient presented at a follow-up visit with a recurrence, and he was readmitted. By hospital day 28, his condition had improved and he was scheduled for discharge. However, he experienced another recurrence just before he was to leave the hospital The circumstances of this second recurrence led us to suspect that the patient was able to produce these signs and symptoms on his own. He was referred for psychiatric evaluation, and findings were negative. He was then sent to the Ear, Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling resolved completely within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up. The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck and shoulder without pneumomediastinum is an uncommon complication of endotracheal intubation. We discuss the clinical and radiographic findings associated with this complication, and we review diagnostic considerations and management.

Introduction

Intubation is the most important procedure during the induction of general anesthesia. Spontaneous trapping of air in the retropharyngeal and associated deep spaces of the neck during intubation is a rare but potentially dangerous complication. Subcutaneous emphysema occurs when air dissects through tissue planes into the neck from the mediastinum. (1)

Numerous cases of cervicofacial emphysema and pneumomediastinum as a complication of dental procedures and oral surgery have been documented in the literature. (1,2) However, traumatic airway and intubation injuries are rare. The literature offers little information regarding subcutaneous emphysema associated with traumatic intubation injuries in the absence of pneumomediastinum. In most cases, emphysema is restricted to the subcutaneous connective tissues of the head and neck. However, if enough air is driven into the subcutaneous tissues, it may track into the thorax and mediastinum. These are life-threatening complications.

In this article, we report what to our knowledge is the first published case of recurrent postintubation subcutaneous emphysema of the face, neck, and pectoralis region in the absence of pneumothorax and pneumomediastinum.

Case report

A previously healthy 21-year-old man was admitted to the Department of Infectious Diseases at our institution with a 15-day history of dull pain and swelling on the right side of his face, which had caused his right eye to close (figure 1). The swelling also involved the right side of his neck and his right shoulder. He denied shortness of breath and chest pain, and he had no recent history of blunt trauma to the area. Two months earlier, he had undergone intestinal surgery trader general anesthesia. Also, he had experienced a scorpion bite on his right hand 45 days earlier. Examination of the left side of the neck and the left shoulder revealed mild tenderness and crepitus. Findings on examination of the oral cavity, oropharynx, and larynx were unremarkable. The patient's heart and lung sounds were normal, he was afebrile, and his vital signs were stable. No sign of infection was found.

[FIGURE 1 OMITTED]

Radiography of the lateral neck revealed the presence of subcutaneous emphysema as well as air in the retropharyngeal space. A chest x-ray and computed tomography (CT) of the chest, head, and neck confirmed the presence of subcutaneous emphysema on the right side (figure 2). No pneumothorax or pneumomediastinum was seen. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. By hospital day 10, the pain and crepitus had resolved, and follow-up x-rays showed less air in the neck and shoulder. The patient was discharged the next day.

[FIGURE 2 OMITTED]

At a clinic follow-up visit 2 months later, the patient presented with recurrence of symptoms and physical findings, and he was readmitted to the hospital. Examination again revealed a marked swelling of the right side of the face and neck and the right shoulder and pectoral region. No changes were seen in the color or temperature of the overlying skin. Crepitus could be palpated on the affected area. Radiography confirmed the presence of subcutaneous emphysema on the right side of the face and neck and the right shoulder; the left side was normal.

The recurrence had been more severe than the initial episode. The patient was hospitalized for observation and did not receive any medical or surgical intervention. During this time, the subcutaneous emphysema progressed from the xyphoid region anteriorly and to the 10th thoracic vertebra posteriorly. No pathology was identified on CT, bronchography, bronchoscopy, and laryngoscopy. Beginning on hospital day 20, the emphysema began to regress slowly, and by day 28, the patient had improved enough to warrant discharge. However, only 2 hours later, he again developed severe subcutaneous emphysema in the right upper body. This second recurrence suggested that the patient had been able to produce these signs and symptoms on his own either by injecting air or by performing Valsalva's maneuver. Physical examination detected no sign of injection, and the results of a psychiatric examination were negative.

The patient was sent to the Ear, Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver. To rule out the presence of a lesion in the aerodigestive tract, we performed an esophageal contrast study with gastrograffin, and it detected no abnormality. The actual cause of the emphysema was not strongly suspected until we again questioned the patient about his intestinal surgery and he revealed that he had been intubated during general anesthesia.

We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling completely resolved within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up.

Discussion

Subcutaneous emphysema can be caused by iatrogenic injury during surgery, endoscopy, or mechanical ventilation. Most cases have been reported to occur following surgical procedures on the mucosa of the mouth, pharynx, esophagus, larynx, or trachea. (3) Other cases have been reported as a result of maxillofacial trauma, (4) dental surgery, (5) adenotonsillectomy, (6) traumatic intubation, (7) ventilator malfunction, (8) and excessive manual ventilation. (9) Spontaneous emphysema has also been reported. (3) The presence of air in the fascial spaces of the neck may also be seen in cases of deep-space infections, neoplasms, and spontaneous perforation of the esophagus (Boerhaave's syndrome). (3) Finally, subcutaneous emphysema can be caused by intubation during the induction of general anesthesia as air becomes trapped in the retropharyngeal and associated deep spaces of the neck.

The anatomic communications between the mediastinum and deep neck spaces have been well studied. The primary conduit for mediastinal air into the deep neck spaces is the so-called danger space. This space is bounded superiorly by the base of the skull, inferiorly by the diaphragm, anteriorly by the alar portion of the deep layer of the deep cervical fascia, posteriorly by the prevertebral portion of the deep layer of the deep cervical fascia, and laterally by the fusion of the alar and prevertebral fascia at the transverse vertebral processes. This space communicates freely with the mediastinum. The vallecula and epiglottis communicate with the retropharyngeal space.

Sometimes trauma can create a defect in the mucosa and open a route for air entry. Air entry can be facilitated by vomiting, coughing, straining, Valsalva's maneuver, and manual ventilation after extubation. The air breaks through the superior constrictor pharyngeal muscle and finds its way easily into parapharyngeal neck spaces, where it dissects potential fascial planes of the neck. The connectivity of the parapharyngeal and retropharyngeal spaces can allow air to extend into the mediastinum and cause pneumothorax. (4) If enough air is driven into subcutaneous tissues, it continues to dissect along the tissue planes that provide the least resistance and track into the thorax and mediastinum. In our patient, the initial onset of subcutaneous emphysema occurred rapidly in the right upper body, but its clinical course was self-limited and benign.

The differential diagnosis of rapid-onset facial or neck swelling includes angioedema, hematoma, allergic reactions, and infection. Crepitus is pathognomonic of subcutaneous emphysema. The absence of crepitus can lead to some diagnostic difficulty. In our patient, x-ray and CT showed that free air was dissecting the soft tissues of the right side of the face and neck and the right shoulder and pectoralis region.

Subcutaneous emphysema also can be caused by anaerobic infection, which should be suspected when a patient exhibits systemic symptoms and local erythema. Antibiotic coverage is recommended and should be directed at oral flora. (5) Penicillin is an appropriate choice for prophylaxis. We administered an antibiotic to our patient upon hospital admission in order to prevent infection. The administration of 100% oxygen via a nourebreather mask reportedly hastens the resolution of emphysema because the oxygen that replaces the air is more readily absorbed.

In most cases of subcutaneous emphysema, complete resolution occurs within a few days. (5) The prognosis is usually good, but complications--including pneumomediastinum, pneumothorax, pneumopericardium, pneumoperitoneum, and orbital emphysema with optic nerve damage--may occur. (9,10) Early diagnosis and management are essential to preventing further complications. It is interesting that our patient did not experience any severe complications.

Our patient's recurrence might have been self-inflicted and associated with an ulterior motive, such as a desire to avoid military service. Following a psychiatric evaluation, we entertained a degree of suspicion that our patient had Munchausen's syndrome. (11) However, we made no attempt to monitor his psychiatric status after he had been discharged from our hospital.

References

(1.) Weber S. Traumatic complications of airway management. Anesthesiol Clin North America 2002;20:503-12.

(2.) Horowitz I, Hirshberg A, Freedman A. Pneumomediastinum and subcutaneous emphysema following surgical extraction of mandibular third molars: Three case reports. Oral Surg Oral Med Oral Pathol 1987;63:25-8.

(3.) Granich MS, Klotz RE, Lofgren RH, et al. Spontaneous retropharyngeal and cervical subcutaneous emphysema in adults. Arch Otolaryngol 1983;109:701-4.

(4.) Minton G, Tu HK. Pneumomediastinum, pneumothorax, and cervical emphysema following mandibular fractures. Oral Surg Oral Med Oral Pathol 1984;57:490-3.

(5.) Josephson GD, Wambach BA, Noordzji JP. Subcutaneous cervicofacial and mediastinal emphysema after dental instrumentation. Otolaryngol Head Neck Surg 2001;124:170-1.

(6.) Miman MC, Ozturan O, Durmus M, et al. Cervical subcutaneous emphysema: An unusual complication of adenotonsillectomy. Paediatr Anaesth 2001; 11:491-3.

(7.) Levine PA. Hypopharyngeal perforation. An untoward complication of endotracheal intubation. Arch Otolaryngol 1980;106:578-80.

(8.) Hilton PJ, Clement JA. Surgical emphysema resulting from a ventilator malfunction. Anaesthesia 1983;38:342-5.

(9.) Vos GD, Marres EH, Heineman E, Janssens M. Tension pneumoperitoneum as an early complication after adenotonsillectomy. J Laryngol Otol 1995;109:440-1.

(10.) Buckley MJ, Turvey TA, Schumann SP, Grimson BS. Orbital emphysema causing vision loss after a dental extraction. J Am Dent Assoc 1990; 120:421-2, 424.

(11.) Altman JS, Gardner GM. Cervicofacial subcutaneous emphysema in a patient with Munchausen syndrome. Ear Nose Throat J 1998;77: 476, 481-2.

From the Department of Infectious Diseases (Dr. Cavuslu and Dr. Oncul), the Ear, Nose, and Throat Service (Dr. Gungor and Dr. Candan), and the Department of Radiodiagnostic Radiology (Dr. Kizilkaya), Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey.

Reprint requests: Oral Oncul, MD, Department of Infectious Diseases, Gulhane Military Medical Academy, Haydarpasa Training Hospital, 81327 Uskudar, Istanbul, Turkey. Phone: 90-216-360-9666; fax: 90-216-348 7880; e-mail: oraloncul@hotmail.com
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Author:Candan, Hasan
Publication:Ear, Nose and Throat Journal
Geographic Code:7TURK
Date:Jul 1, 2004
Words:2029
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