Subglottic Air Escape Causing Subcutaneous Emphysema

Abstract

Objectives: Closure of a tracheocutaneous fistula risks air escape into the anterior neck. Vocal cord augmentation establishes a subglottic pressure gradient during exhalation. We present a patient who underwent these procedures concurrently in whom subcutaneous subsequently developed. Methods: A 66 year-old female developed a neck abscess following a dental procedure. She presented to the ER with a compromised airway, requiring intubation. She underwent two separate neck abscess drainage procedures by OMFS. Prolonged intubation necessitated a tracheotomy, performed by cardiothoracic surgery. She was subsequently weaned and decannulated. Results: She was referred for dysphonia and a micro-tracheocutaneous fistula. Laryngoscopy revealed left vocal cord paralysis, not thought to be iatrogenic. Fistula closure with vocal cord augmentation was proposed. Fistula tract excision was followed by a two-layer muscle and skin closure. An air-tight seal was confirmed on high-pressure ventilation. Gelfoam was injected into the left vocal cord. She was discharged the morning after surgery. Twelve hours later she returned to the ER with rapid onset of cervicofacial subcutaneous emphysema. A pressure dressing was applied to the anterior neck. The subcutaneous emphysema subsided, being sub-totally resorbed within 24 hours. Conclusions: Despite the delay in onset, once conditions developed a percentage of subglottic air preferentially escaped through the small defect in the anterior tracheal wall, rather than exclusively through the larger hemi-glottic aperture, causing subcutaneous emphysema. Caution should be exercised in performing these procedures simultaneously.