Marta CardosoHospital de São JoãoEmail: mrodriguescardoso@hotmail.comPhone: 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, 57:996-9992 – 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): 631-6453 - 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-e384 – Josephson G, Wambach B, Noordz P, Subcutaneous Cervicofacial and Mediastinal Emphysema After Dental Instrumentation, Otolaryngol Head Neck Surg 2001; 124: 170-171

CONCLUSIONS

DISCUSSIONCASE REPORTCASE REPORT

REFERENCES

Figure 3 (a, b) – TC image 3rd day (axial view) Figure 4 (a, b, c, d) – TC image 3rd day (sagital and coronal views).

Figure 1 (a, b, c, d, e, f, g).- TC image 1st day. Figure 2 (a, b, c, d) – TC image 3rd

day (axial view).

ABSTRACT

CONTACT

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