A 61 y.o. woman presents with OSA presents with L sided facial pain a day after a wisdom tooth was extracted
Why does she have pain?
Our patient had subcutaneous air in the neck caused by a high speed drill while her wisdom tooth was being extracted. This was made worse by her nocturnal positive pressure ventilation.
Subcutaneous emphysema was first recognized by Laennec who reported it as a consequence of trauma in 1819. In 1939, Dr. Louis Hamman described it in a postpartum woman and subcutaneous emphysema in the mediastinum is now known as Hamman’s crunch. Subcutaneous air can be related to infection and gas in the tissues related to serious infection as in necrotizing fasciitis. The following is a review of noninfectious causes of subcutaneous gas. These are cases where air is introduced into potential spaces such as subcutaneous tissues and travels along fascial planes.
DENTAL /ENT causes of subcutaneous emphysema
This can occur after dental procedure usually the result of high pressure air/water syringes or high speed drills. Trauma and surgery represent common causes of subcutaneous air. More recently minimally invasive chondrolaryngoplasty has been associated with subcutaneous air. This procedure involves shaving the thyroid cartilage in patients who are transgender.
pt seen four days ago in the ED sp minimally invasive chondrolaryngoplasty with air travelling through the incision site into the neck.
Often the patients present with pain or a feeling of fullness in the neck. On exam there is a feeling of crepitus ; best described as touching Rice Krispies.
THORACIC causes of subcutaneous emphysema
Pneumothorax either spontaneous or iatratrogentic (related to bag valve mask or ventilator, foreign bodies, trauma)
Barotrauma causing alveolar rupture and pneumomediastinum without pneumothorax which often occurs in asthmatics, divers and weight lifters.
GI causes of subcutaneous emphysema
Perforated viscus- diverticulum, stomach, esophagus or small bowel
Imatinib can induce pneumatosis and lead to pneumomediastinum.
spontaneous pneumatosis and pneumomediastinum in a patient with leukemia
GU/GYNE causes of subcutaneous emphysema
CO2 can leak around ports during minimally invasive surgery and scrotal edema may develop.
Vaginal pressure during pregnancy by douching or blowing air into the vagina can result in subcutaneous air because of dilated pelvic vessels.
Routine vaginal delivery can result in pneumomediastinum.
Subcutaneous emphyema usually resolves in 2 to 10 days without treatment . In cases of severe edema of the head and neck 2 cm infraclavicular incisions bilaterally or a subcutaneous drain superficial to the pectoralis fascia have been tried. Occasionally the subcutaneous emphysema may become life-threatening if it is accompanied by tension pneumothorax, compartment syndrome, infection or air embolism. Most patients are treated with antibiotics in case bacteria has been introduced. The history is valuable because if the problem occurred immediately after a procedure infection is less likely. .
pt with air embolus after dental extraction. treatment is L lateral decubitus position and hyperbaric oxygen which increases the partial pressure of oxygen causing diffusion of nitrogen from inside the air bubble and reduction in size.
Our patient was treated with augmentin and discharged.
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