Marta Cardoso Hospital de São João Email: [email protected] Phone: 00351914237272 Objectives: Subcutaneous emphysema occurs when air is forced beneath the soft tissues, leading to swelling, crepitus on palpation and potential to spread along fascial planes. Cervicofacial emphysema and pneumomediastinum are complications associated with surgery in the head and neck, infectious diseases and trauma. The occurrence of this complication after dental extraction is uncommon. Methods: A case report is presented and the literature reviewed. Results: A twenty-five-year-old man presented to the emergency department complaining of swelling and pain in the face and neck after dental extraction. He had crepitus on cervical palpation without thoracic complaints. Fiberoptic laryngoscopy did not reveal glottic lumen compromise. Computed tomography scan (CT) of the neck showed extensive subcutaneous emphysema and pneumomediastinum . The patient remained in observation for dyspnea, dysphagia and potencial infectious signs with a favorable outcome. Conclusion: The authors present a case of an extensive subcutaneous emphysema and pneumomediastinum secondary to dental extraction and discuss the mechanisms, clinical presentations and possible complications. The literature is reviewed. Cervicofacial Emphysema and Pneumomediastinum: a Case Report Cardoso M, MD, Araujo J, MD, Cardoso E, MD, Santos M, MD Department of Otolaryngology – Head and Neck Surgery, Hospital de São João, Porto, Portugal A twenty-five-year-old man presented to the emergency department complaining of swelling and pain in the face and neck after dental extraction one day earlier. He denied odynophagia, dysphagia and dyspnea. He was otherwise healthy, with no significant past medical or surgical history. At examination, the patient was hemodynamically stable, with no fever or signs of respiratory distress. His voice was normal. On intraoral inspection, the wound was sutured and there was a slight swelling of the surrounding area but no crepitus. He had crepitus on cervical palpation without thoracic complaints. Fiberoptic laryngoscopy did not reveal glottic lumen compromise. The remainder of the physical exam was normal. Laboratory blood tests and electrocardiography did not show abnormalities. Computed tomography scan (CT) of the head, neck and thoracic regions showed extensive air accumulation in the subcutaneous tissue of the neck, face and mediastinum and the diagnosis was extensive subcutaneous emphysema and pneumomediastinum. The patient was admitted for observation and intravenous antibiotics, being discharged in the sixth day with resolution of the clinical symptoms and radiological improvement. The etiology of subcutaneous emphysema and pneumomediastinum can be iatrogenic, traumatic, infectious, or spontaneous. The most common cause is iatrogenic, usually secondary to head and neck surgery, intubation, mechanical ventilation and dental surgery. Traumatic etiology often relates to facial bone fracture, intraoral, aerodigestive tract or chest wall trauma. It can also occur spontaneously in those with previous pulmonary disease with increased intra- alveolar pressure or weakened alveolar walls. As a dental extraction complication, it is a rare cause and usually results from the use of high-speed dental drills and air and water dental syringes. 2 Postoperative subcutaneous emphysema and pneumomediastinum after a dental procedure were first reported 100 years ago when a musician blew a bugle immediately after tooth extraction. The signs of subcutaneous emphysema are edema, sudden cervical swelling without significant tenderness, and crepitus on palpation. The features that suggest a pneumomediastinum are dyspnea with a brassy voice, chest or back pain, and Hamman sign. However, in the majority of cases, the clinical picture is limited to mild swelling and discomfort, and many cases go unrecognized. Differential diagnosis should include allergy and infection. 3 Cases with more diffuse involvement are admitted for airway observation, 100% oxygen and intravenous antibiotics. A case report is presented and the literature reviewed. Cervicofacial emphysema and pneumomediastinum are possible complications from dental procedures and once the otolaryngologist is often called to evaluate such a condition he should remember this possible cause. Early diagnosis and management is essential in preventing further complications. 4 Subcutaneous emphysema is an entity that occurs when air is forced beneath the soft tissues, leading to swelling, crepitus on palpation and potential to spread along fascial planes. Once bellow the dermal layer, the air can remain at the surgical site or continue to spread, passing trough the masticatory space to the retropharyngeal and parapharyngeal spaces, and reaching the mediastinum. If the inflowing air contains bacteria, serious infection may ensue. 1 Cervicofacial emphysema and pneumomediastinum can be complications associated with surgery in the head and neck, infectious diseases, trauma, iatrogenic and spontaneous. The occurrence of this complication after dental extraction is uncommon and the otolaryngologist should be aware of this possible cause. 2 The authors present a case of an extensive subcutaneous emphysema and pneumomediastinum secondary to dental extraction. INTRODUCTION METHODS AND MATERIALS 1 - Capes J, Salon J, Wells D, Bilateral Cervicofacial, Axillary, and Anterior Mediastinal Emphysema: A Rare Complication of Third Molar Extraction, J Oral Maxillofac Surg, 1999, 57:996-999 2 – Yang S, Chiu T, Lin T, Chan H, Subcutaneous Emphysema and Pneumomediastinum Secondary to Dental Extraction: a Case Report and Literature Review, Kaohsiung J Med Sci, 2006; 22(12): 631-645 3 - Arai I, Takayuki A, Yamazaki H, Ota Y, Kaneko A, Pneumomediastinum and Subcutaneous Emphysema After Dental Extraction Detected Incidentally by Regular Check-up: a Case Report, Oral Radiol Endod, 2009; 107:e33-e38 4 – Josephson G, Wambach B, Noordz P, Subcutaneous Cervicofacial and Mediastinal Emphysema After Dental Instrumentation, Otolaryngol Head Neck Surg 2001; 124: 170-171 CONCLUSIONS DISCUSSION CASE REPORT CASE REPORT REFERENCES Figure 3 (a, b) – TC image 3 rd day (axial view) Figure 4 (a, b, c, d) – TC image 3 rd day (sagital and coronal views). Figure 1 (a, b, c, d, e, f, g).- TC image 1 st day. Figure 2 (a, b, c, d) – TC image 3 rd day (axial view). ABSTRACT CONTACT 2.a 2.b 2.c 2.d 3.a 3.b 4.a 4.b 4.c 4.d 1.a 1.b 1.c 1.d 1.e 1.f 1.g