Extensive Subcutaneous Emphysema Research Articles

Air under pressure: a case report on tension pneumomediastinum arising from traumatic injury

Abstract Background Tension pneumomediastinum (TPM) is a rare but critical condition characterized by the accumulation of air in the mediastinum, leading to increased intrathoracic pressure and cardiovascular compromise. This case report is novel due to the rarity of TPM arising from blunt chest trauma and the necessity for emergent surgical intervention after initial conservative management failed. Case presentation A 63-year-old male presented with severe chest pain and dyspnea following a high-impact motor vehicle collision. Initial assessment revealed tachypnea, tachycardia, and hypotension, along with extensive subcutaneous emphysema over the chest and neck. Imaging confirmed pneumomediastinum and bilateral pneumothoraxes, consistent with TPM. Despite initial management with high-flow oxygen and bilateral chest tube insertion, the patient’s condition deteriorated, necessitating emergent mediastinal decompression via an anterior subxiphoid incision. This intervention resulted in immediate hemodynamic improvement. Conclusions This case underscores the importance of recognizing TPM in patients with chest trauma and highlights the need for prompt surgical intervention in cases of hemodynamic instability. Early and accurate diagnosis and timely surgical management are crucial for improving patient outcomes in TPM.

Ulcerative colitis complicating pneumomediastinum, subcutaneous emphysema and pneumothorax.

A 17-year-old man with ulcerative colitis (UC) presented to our hospital with neck pain and fever after vomiting. On examination, a snowflake sensation was noted in the neck. A chest radiograph showed extensive subcutaneous emphysema in the chest. CT scans showed extensive subcutaneous emphysema in the neck, shoulders and axilla, as well as pneumomediastinum and pneumothorax. A diagnosis of pneumomediastinum with exacerbation of UC was made, and he was fasted and treated with antibiotics. Intensive granulocyte and monocyte adsorption apheresis (GMA) was started for exacerbation of UC. His symptoms and the radiological findings of pneumomediastinum improved. He remained in remission on azathioprine. UC is a chronic inflammatory bowel disease (IBD) associated with extraintestinal manifestations (EIM). Very few cases have been complicated by pneumomediastinum. The increase in alveolar pressure due to vomiting and systemic inflammation-related pleural or esophageal damage may cause pneumomediastinum in this case. Prevention of progression to mediastinitis and treatment of exacerbated UC are contradictory. GMA was successful because it was not an immunosuppressive therapy. Our case highlights that rare EIM may complicate exacerbation of UC.

Beyond breathless: a case of air infiltrating every cavity

Hawaii attracts 10 million tourists annually, with non-residents accounting for 9% of trauma cases, half of which are water-related. We experienced a SCUBA tank injury, causing extensive trauma from pressurized air release. A 53-year-old female, post-Scuba diving, fell onto a SCUBA tank, causing rapid pressurized air discharge. She presented with perineal pain, bloating, and extensive subcutaneous emphysema. CT revealed air in every possible cavity. Thoracostomies and exploratory laparotomy performed, revealing an 80-90% anal sphincter transection. An overlapping anal sphincteroplasty with diverting loop ileostomy was performed. Recovery was uncomplicated. This unique case involves a traumatic SCUBA tank air release causing extensive damage. The patient avoided direct anorectal entry, preventing catastrophic damage but sustained an anal sphincter complex injury. Air likely entered the peritoneum through the levator ani, causing pneumoperitoneum and pneumothoracies. The extensive damage emphasizes the need for safe water sports practices. The patient’s recovery highlights the human body’s resilience in unique situations.

EP554 - Sigmoid Diverticular Perforation Mimicking Boerhaave Syndrome – A Case Report

Abstract Introduction Subcutaneous emphysema is a rare presenting complaint and can represent severe underlying pathology. Atypical occurrences of abdominal emphysema in diverticular perforations have been reported but emphysema within the thorax and neck due to sigmoid perforation is rare. We present an elderly male patient who presented with neck surgical emphysema secondary to diverticular perforation. Case presentation A 78-year-old man presented with two days history of shortness of breath and two weeks history of abdominal pain worse on coughing, newly hoarse voice, one episode of vomiting and fever. His past medical history included palliative malignant melanoma, ischaemic heart disease, asthma and chronic kidney disease. At presentation, he was tachycardic and had 95% oxygen saturation. Physical examination revealed extensive upper body subcutaneous emphysema and tender lower abdomen. Admission blood tests showed white cell count of 9.8 x 109 and C-reactive protein of 148mg/L. Urgent contrast CT scan with oral contrast excluded oesophageal perforation but demonstrated perforated sigmoid diverticulum. Due to the patient’s extensive co-morbidities and limited intra-abdominal contamination, he was managed conservatively. Discussion The patient initially had CT chest with IV contrast followed by CT with oral contrast, encompassing the abdomen and pelvis, leading to the accurate diagnosis. The presumed path of gas tracking from the perforation through the diaphragmatic hiatus contributed to the delay in reaching the correct diagnosis. In cases where patients present with subcutaneous emphysema in the upper body, particularly when CT thorax with oral contrast has ruled out oesophageal perforation, clinical suspicion for intra-abdominal causes should persist. Despite the presence of significant surgical emphysema, this patient demonstrated a favourable response to conservative measures.

Total mastectomy in severe necrotic mastitis in a pet goat complicated by a post‐operative generalised emphysema

AbstractA total mastectomy was the treatment of choice in a 10‐year‐old pet doe Pika with a history of severe necrotic mastitis secondary to a precocious udder. Following an elliptical skin incision, the mammary tissue was bluntly excised. Because of a large surgical defect, severe skin tension was needed to close the wound completely. A passive drain was placed in the surgical site to remove excess fluid, and the animal received antibiotic and anti‐inflammatory treatment. On the fifth day after the surgery, the drain was removed and palpation revealed an extensive subcutaneous emphysema at the surgical site as well as the back and neck of the animal. The antibiotic treatment was prolonged, and the animal kept for observation. After 3 weeks, the wound had healed completely, and the doe was discharged.

Subcutaneous Emphysema Following Laser Assisted Dilation of Subglottic Stenosis: A Case Report

Introduction: Subcutaneous emphysema is characterized by the accumulation of air beneath the dermal layers of the skin. We present a case of extensive subcutaneous emphysema of the neck, face and arms in a patient who was two days post operative from laser assisted dilation of subglottic stenosis. Materials and Methods: We present a case of subcutaneous emphysema in a patient who presented to the emergency department. As this is a case report, no additional materials or specific methods were required. Case Presentation: A 71-year-old man with history of tracheal stenosis status post laser assisted subglottic dilation presented to the emergency department two days post-operatively for progressively worsening swelling of the face, neck and arms. Physical exam was notable for crepitus of the face, neck and arms. Oropharyngeal exam showed no edema to the posterior oropharynx or tongue. Breathing was non-labored without stridor. Imaging revealed extensive subcutaneous emphysema without any obvious source. The otolaryngology (ENT) service evaluated the patient and admitted him to their service. Initially he was managed conservatively via observation and supportive care however, on day two of hospitalization his respiratory status worsened. He required intubation and tracheal stent placement. The tracheal defect was never found on exploration in the operating room, suggesting the defect was sub-centimeter in size. He was extubated on hospital day four and discharged with a plan to have the tracheal stent in place for three months. Conclusion: Subcutaneous emphysema secondary to a tracheobronchial tree defect is a known complication of laser dilatation of subglottic stenosis. Most cases resolve spontaneously and can be managed conservatively. However, patients require close airway monitoring as some may require emergent airway management. Clinicians should be aware of this complication and subsequent management.

Significant Spontaneous Pneumomediastinum and Extensive Subcutaneous Emphysema in a COVID-19 Patient

A 64-year-old man, who had no pre-existing health conditions, was admitted to the intensive care unit due to progressive shortness of breath resulting from COVID-19. Initially, the patient responded to non-invasive mechanical ventilation, which improved his breathing function. However, after six days, his respiratory function worsened significantly, requiring invasive ventilation. Out of nowhere, the person experienced spontaneous pneumomediastinum and extensive subcutaneous emphysema. The next day, a spontaneous pneumothorax occurred and was successfully drained later. It became evident that there was extensive subcutaneous emphysema also. The CT scan of the chest confirmed the presence of spontaneous pneumomediastinum, but it did not have any effect on the patient’s hemodynamics. The physicians performed a bronchoscopy and imaging with a contrast medium, which ruled out any lesions to the trachea or esophagus. No other issues related to the problem were identified during the examination. Unfortunately, microscopic bullae of interstitial emphysema, or micro air leaks, are visible when they are an adequate size on computed tomography. Recent literature and studies not available during the case report have shown that if the Macklin effect is detected on the baseline CT scan, it could predict the occurrence of pneumothorax or pneumomediastinum.

Rare case of pseudo-pneumoperitoneum as a triad of extensive subcutaneous emphysema and pneumomediastinum as a complication of non-invasive respiratory support

Respiratory support through non-invasive ventilation and high-flow nasal cannula is frequently used in patients with acute respiratory failure as a way to maintain oxygenation without intubation. Although mostly well-tolerated, infrequent but increasingly recognized complications can occur, such as pneumothorax, pneumomediastinum, and subcutaneous emphysema. This likely occurs as a result of alveolar rupture from barotrauma related to ventilatory support and dissection of higher-pressure air along the pulmonary interstitium and into the anatomic cavities of the chest. We present a rare case of pseudo-pneumoperitoneum as a result of non-invasive respiratory support. This occurred as part of a triad of pneumomediastinum and extensive subcutaneous emphysema extending circumferentially around the abdomen and into the scrotum of a hypoxic patient with congestive heart failure and chronic obstructive pulmonary disease exacerbation with pneumonia requiring aggressive respiratory support.

Síndrome de Hamman e a importância do controle da asma: relato de caso e revisão da literatura

INTRODUCTION: Hamman syndrome is a condition that affects 1 in every 25,000 people, between 5 and 34 years of age, the majority of whom are male (70%) and have a long body type. Its clinical repercussions can compromise the patients quality of life, making it necessary for them to be aware of and adopt preventive measures. OBJECTIVE: To describe a case report on Hamman syndrome and its correlation with asthma, as well as the importance of therapeutic adherence and knowledge among health professionals. CASE REPORT: preschooler, male, white, with BMI of 20.5 kg/m2, was admitted to the service with an asthma attack for 5 days, associated with chest pain and worsening cough for 1 day, progressing to subcutaneous emphysema. He was eupneic, afebrile, without respiratory effort, with reduced breath sounds and subcrepitant rales in the left posterior base of the right hemithorax, subcutaneous emphysema that initially involved the thoracic circumference, and later expanded to the anterior cervical and supraclavicular region, bilaterally. He was taking his asthma medication irregularly. Chest tomography showed extensive subcutaneous emphysema, pneumomediastinum and pneumorrhacs. Due to the suspicion of Hamman syndrome, expectant management and observation in the infirmary bed were advised. The patient was discharged from hospital after clinical improvement, and was referred for follow-up at the service's pediatric pulmonology outpatient clinic. CONCLUSION: Disseminating knowledge about this rare condition among healthcare professionals may allow for adequate patient management, as well as preventing relapses and unfavorable clinical outcomes.knowledge about this rare condition among healthcare professionals may allow for adequate patient management, as well as preventing relapses and unfavorable clinical outcomes.

Traumatic air myelogram

We present the case of a 60-year-old male patient admitted to our intensive care unit after a high-velocity car accident. On-site clinical examination revealed normal consciousness with no focal deficits. Chest X–Ray was suggestive of right pneumothorax with pneumomediastinum and extensive subcutaneous emphysema. CT scan revealed right pneumothorax, pneumomediastinum, extensive subcutaneous emphysema and extradural pneumorachis. A right tube thoracostomy was done and the patient was placed on High flow nasal cannula at 40 lpm and 100% FiO2. There was a gradual resolution of pneumothorax and all the extra-alveolar air including pneumorachis by the 7th day. The patient was discharged in a clinically stable condition. Keywords: Pneumothorax, Pneumomediastinum, Pneumorachis

Management of Extensive Subcutaneous Emphysema with Blow Hole Infraclavicular Incision and Continuous Suction Installation

Background: Subcutaneous emphysema often occurs in cases of implanted pneumothorax chest tubes and must always be evaluated. Subcutaneous emphysema is a condition where air or gas is found in the tissue under the skin.
 Case presentation: A 49-year-old man was treated for sudden shortness of breath that occurred after a violent cough accompanied by pain and heaviness in the chest area 1 day before admission to the hospital. The patient had previously received anti-tuberculosis drug treatment for 6 months based on chest X-ray results in 2022, and the patient had undergone a rapid molecular test (TCM) examination, mycobacterium tuberculosis (Mtb), and obtained Mtb results not detected. Lung auscultation obtains sound intensity breath weakness until it disappears in both lung fields. Palpation of the skin revealed widespread crepitus on the face, neck, upper extremities, back, chest, and abdomen. The range of motion areas of the neck, shoulders, and hands are limited due to pain with movement. Evaluation of the chest tube obtained: the chest tube was installed in the anterior axillary line on the right at the level of the 5th intercostal space with number 10 attached to the chest wall and the chest tube well fixed to the chest wall. The end chest tube has been connected to the WSD bottle, and evaluation of the WSD shows that there are undulations and bubbles.
 Conclusion: The patient was admitted with spontaneous pneumothorax secondary to tuberculosis and was implanted with a chest tube.

Pneumo-mediastinum, pneumoperitoneum, and pneumo-scrotum with extensive increasing subcutaneous emphysema: a rare presentation of colonic perforation

BackgroundColonic perforation usually presents with classical signs of peritonitis. However, isolated retroperitoneal colonic perforation can present with varied clinical signs and symptoms and pose diagnostic challenges. Pneumo-mediastinum and abdominal subcutaneous emphysema can be one of the presenting signs of colonic perforation.Case reportA 33-year-old male presented with abdominal distension and extensive subcutaneous emphysema over the abdomen, pneumo-mediastinum, and pneumo-scrotum secondary to sigmoid colon perforation from a foreign body. The patient did not have classical signs of peritonitis.ConclusionBeing vigilant about the potential of colonic perforation is crucial when observing a significantly increasing subcutaneous emphysema across different parts of the body. Attending clinicians should always keep intraabdominal pathology in mind when a direct cause for these symptoms cannot be found and the patient’s symptoms become progressive.

Airway Compromise Due to Extensive Subcutaneous Emphysema Following Trauma: A Case Report

Subcutaneous or surgical emphysema (SE) following chest trauma is usually not of major concern in itself and tends to be self-limiting, provided the underlying cause has been addressed. Occasionally, a patient may present with massive SE which may threaten the patient’s airway and breathing. It is important for clinicians to have a management approach to such patients. Here we present such a case that was admitted to our hospital, describing the management approach and review the existing literature on the subject.

Surgical emphysema and pneumothorax: Unfamiliar combination in Ehlers-Danlos syndrome

A 53-year-old gentleman presented with sudden onset swelling over the neck for the past 5 days. It was associated with dyspnoea on exertion. He was a known patient of Ehlers-Danlos syndrome since sixteen years of age. Initially, the swelling appeared over the neck which gradually progressed over to the anterior chest wall and the nape of the neck. There was no history of trauma, fever, surgery or similar complaints in the past. He was a known smoker. On examination, there was diffuse subcutaneous emphysema over the neck, and the anterior chest wall (Figure 1). Skin crepitus was present. The skin was hyper-extensile, fragile and easily stretchable (Figure 1). The patient was vitally stable. On rigid laryngoscopy, bilateral vocal cords were mobile. We admitted the patient and performed a CT scan of the neck and chest to assess the extent of the emphysema. CT scan confirmed an extensive subcutaneous emphysema over the neck, extending posterior to the oesophagus. There were multiple emphysematous bullae over the apical region of the right lung and an area of pneumothorax just in the vicinity of the bullae (Figure 2). The patient was planned for incision and evacuation of the air. A horizontal incision was given over the most prominent part of the swelling and the air was milked out gently. An Intercostal Chest Drain (ICD) was inserted and the condition was closely monitored. The recovery was uneventful. He was discharged after seven days of hospital stay.

A study of subcutaneous emphysema, factors contributing to its development, resolution and management with different modalities.

Subcutaneous emphysema (SE) is defined as an escape of air in subcutaneous tissue. It is one of the most common complications after intercostal chest tube drainage. SE is usually benign, requiring no specific treatment, but extensive SE can be uncomfortable and alarming for the patient. It can rarely lead to airway compromise, respiratory failure, and death. Factors leading to its development, following chest tube insertion and methods of management, have not been extensively studied and published. This was an analytical study done over 2 years on indoor patients who developed SE. These cases were managed using four different modalities and were analyzed for various factors contributing to the development, severity, and resolution of SE. The results of this study highlight that the cases of hydropneumothorax and secondary pneumothorax were significantly more predisposed to the development of severe SE (following intercostal chest tube insertion) and large air leaks as compared to others. A larger air leak develops higher grades of SE. The average time for resolution of SE was similar among the different modalities of management compared in the study.

Association of Chest Anteroposterior Radiography with Computed Tomography in Patients with Blunt Chest Trauma.

In cases of chest trauma, computed tomography (CT) can be used alongside chest anteroposterior (AP) radiography and physical examination during initial evaluation. Performing a CT scan may be difficult if a patient has unstable vital signs. In contrast, radiography may not always reliably diagnose nonmarked pneumothorax or extensive subcutaneous emphysema. This study aimed to determine the agreement between chest radiography and CT findings in patients with blunt chest trauma. The study also aimed to determine the occurrence of occult pneumothorax and clarify the proportion of subcutaneous emphysema and pneumothorax detected through radiography and CT, respectively. We included patients (n = 1284) with chest trauma who were admitted to the emergency room of a tertiary hospital between January 2015 and June 2022. We excluded patients aged <18 years, those with stab injury, those without radiography and CT findings, and patients who required iatrogenic intervention, such as chest tube insertion, before imaging. We recorded age, sex, trauma mechanism, and Abbreviated Injury Scale score for each patient. From radiography and CT scans, we recorded the presence of rib fracture, subcutaneous emphysema, lung contusion, pneumothorax, and pneumomediastinum. The accuracy, sensitivity, specificity, and positive and negative predictive values were calculated to assess the reliability of radiography as a predictor of CT-based diagnosis. Radiography exhibited a specificity of nearly 100% for all items. In most cases, findings that could not be confirmed by CT were not evident on radiographs. The incidence of occult pneumothorax was 87.3%. When subcutaneous emphysema was observed on radiography, CT findings indicated pneumothorax in 96.7% of cases. In situations where the patient's vital signs are unstable and performing a CT scan is not feasible, the presence of subcutaneous emphysema on radiography may indicate the need for chest decompression, even if pneumothorax is not observed.

Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report

Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.

Decompression Technique Using Subcutaneous Angiocatheter Insertion to Relieve Extensive Subcutaneous Emphysema: A Case Report

BackgroundTrauma, pneumothorax, complication of surgery, infection, or malignancy can cause subcutaneous emphysema and although most subcutaneous emphysema cases are self-limited, extensive subcutaneous emphysema can lead to a compromised airway and cardiovascular system. In this report, we described a successful treatment strategy in which subcutaneous angiocatheter insertion was used to relieve the pressure of extensive subcutaneous emphysema. Case ReportAn 83-year-old man was received at the emergency department (ED) for recurrent pneumothorax and extensive subcutaneous emphysema. Six 18-gauge angiocatheters were inserted under the thoracic subcutaneous tissue and a noticeable improvement was seen 3 h after angiocatheter insertion. Why Should an Emergency Physician Be Aware of This?Subcutaneous angiocatheter insertion may be a safe and uncomplicated decompression technique to relieve extensive subcutaneous emphysema, particularly in the ED.

Novel management of extensive subcutaneous emphysema in cardiac surgery: cases presentation

Subcutaneous emphysema occurs when air is trapped between subcutaneous tissues and manifests as sudden swelling, dysphonia, and sore throat. In many severe cases, subcutaneous emphysema causes dysphagia, pain, and breathing difficulty. The current study reports two cases of successful management of extensive subcutaneous emphysema after cardiac surgery.&#x0D; The first patient was a 60-year-old man with a history of coronary artery disease who underwent coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass. He was transferred to the intensive care unit (ICU) in good condition. Twelve hours after the surgery, he was extubated in a stable condition. On the second day after the surgery, his face, neck, and chest began to swell due to extensive subcutaneous emphysema, and he experienced decreased SPO2 and severe respiratory distress.&#x0D; The second patient was a 65-year-old woman with a history of myocardial infarction (MI) who had CABG off-pump surgery. After surgery, the patient was transferred to the ICU in a favorable and stable condition and was extubated 6 hours after the surgery. Her face, neck, and chest started swelling three days after the surgery, and she had severe respiratory distress and decreased blood saturation due to extensive subcutaneous emphysema.&#x0D; In both cases, despite conventional treatment, the patient's symptoms escalated despite re-intubation and mechanical ventilation.In the operating room, the chest tubes were removed, two new chest tubes were inserted, and the area damaged by the old tubes was repaired. Shortly after the insertion of the chest tubes, the patient's emphysema symptoms decreased significantly.

Extensive subcutaneous emphysema secondary to endodontic treatment.

Subcutaneous emphysema is a relatively rare phenomenon, in the context of dentistry related to iatrogenic injury, with only 32 cases reported between 1993 and 2008. This article aims to discuss the relevance and importance of this issue to dentists, including how to identify the condition and its management.