A CASE OF MASSIVE SUBCUTANEOUS EMPHYSEMA (SE) AND PNEUMOMEDIASTINUM (PM)

Abstract

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Spontaneous subcutaneous emphysema and pneumomediastinum are self-limiting conditions needing only supportive therapy, but in some rare cases, surgical intervention is employed to abort respiratory or circulatory compromise. CASE PRESENTATION: A 76-year-old male with a past medical history of chronic obstructive pulmonary disease, bronchiectasis complicated by mycobacterium avium intracellulare and allergic bronchopulmonary aspergillosis (ABPA), who presented with history of persistent productive cough, acute onset left sided pleuritic chest pain with associated left neck and eye swelling. Examination of his eyes was significant for bilateral upper and lower eye lid swelling that was worst over the left lower eyelid that prevent visualization of the eyeball. There was associated enlargement of his neck that extended from his ear to his clavicles with palpable crepitus. His lung exam was notable for diffuse rales and rhonchi without associated wheezing. Contrast enhanced computed tomography (CT) scan of the neck and thorax was performed, which revealed severe diffuse subcutaneous emphysema tracking through the neck, extending into the left periorbital soft tissues, small foci of gas tracking into the left retrobulbar space, pneumomediastinum and intrathoracic air collection secondary to the rupture of a right lower lobe bleb. Patient was transferred to a thoracic center on the 4th day into his admission due to respiratory deterioration. In the setting of his progressive emphysema, dysphagia, and worsening respiratory distress a pneumatic decompressive via infraclavicular incisions were performed. He was continued on steroids, supplemental oxygen, incentive spirometry, chest physiotherapy and serial chest x-ray were performed. Patient had an overall improvement in his respiratory statue and was discharged to a rehabilitation center to continue pulmonary rehabilitation. DISCUSSION: The common presenting complaint associated with this condition includes chest pain, dyspnea, cough, neck pain, dysphagia, and dysphonia. The potential causes include blunt or penetrating chest trauma, valsalva maneuvers, coughing, inhalation of illicit drugs and strenuous activities. The pathophysiology of subcutaneous emphysema and pneumomediastinum occurs with broncho-alveolar rupture of a weakened alveolar wall secondary to chronic lung pathology, precipitated by increased intra-thoracic pressure. The main treatment modalities include bed rest, oxygen supplementation, analgesia, incentive spirometry, and pulmonary toileting. Infraclavicular incisions or placement of subcutaneous drains are the 2 most common surgical intervention used. CONCLUSIONS: SE and PM patient’s most often benefit from supportive measures such as best rest and supplemental oxygen. The benefit for surgical management has not been established but it can be offered in severe cases that have been refractory to conservative therapy. Reference #1: Kiefer MV, Feeney CM (2013) Management of Subcutaneous Emphysema with "Gills": Case Report and Review of the Literature. J Emerg Med 5: 666-669 Reference #2: Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, et al. (2015) Classification And Management Of Subcutaneous Emphysema: A 10-Year Experience. Indian J Surg 77: 673-677 Reference #3: Kim K.S., Jeon H.W., Moon Y., Kim Y.D., Ahn M.I., Park J.K. Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment. J. Thorac. Dis. 2015;7:1817–1824 DISCLOSURES: No relevant relationships by Olayiwola Amoran, source=Web Response No relevant relationships by Omar Ayah, source=Web Response No relevant relationships by Biren Desai, source=Web Response No relevant relationships by Zainab Mahmoud, source=Web Response