Subcutaneous Emphysema Of Neck Research Articles

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

Spontaneous Pneumomediastinum in a Young Gentleman

Spontaneous pneumomediastinum (SPM) is defined as presence of free air or gas in the mediastinum. It may occur in young healthy individuals without serious underlying lung disease. SPM is a rare presentation at the Emergency Department; it typically occurs among tall and thin individuals. We report a case of spontaneous pneumomediastinum in a gentleman who presented with a short history of chest and neck pain after coming back from work. Neck radiograph showed neck subcutaneous emphysema and chest radiograph showed pneumomediastinum with no evidence of pneumothorax or rib fracture.

A CASE REPORT: ACUTE EXACERBATION OF BRONCHIAL ASTHMA COMPLICATED BY PNEUMOMEDIASTINUM

Pneumomediastinum is presence of air or other gas in the mediastinum. Also known as mediastinal emphysema, is one of several forms of aberrant extra-alveolar air [1]. Obstructive lung diseases, especially acute asthma, is a well described predisposing factor leading to pneumomediastinum [2]. A 22-year male, known case of bronchial asthma presented with productive cough and cold since 2 days, breathlessness and wheezing since 1 day, Chest pain and pain in neck since 2 hours. Physical examination revealed bilateral ronchi and subcutaneous emphysema of neck and right upper chest. CT thorax showed Pneumomediastinum and subcutaneous emphysema. Patient was treated with high ow oxygen via NRBM mask and bronchodilators. Successive CT thorax showed resolution of Pneumomediastinum and subcutaneous emphysema and no evidence of oesophageal rupture. Patient was discharged after 7 days

A young healthy female with idiopathic extensive subcutaneous emphysema occurring in neck, mediastinum, left arm, peritoneal and retroperitoneal spaces: A case report

This is a case of a young healthy female patient with idiopathic extensive subcutaneous emphysema in neck, mediastinum, left arm, peritoneal and retroperitoneal spaces. The patient presented to the emergency department and then admitted to the ward for monitoring of vitals, evaluation and to manage her accordingly. The patient had a surgical intervention to release emphysema. She improved significantly postsurgery. She stayed in hospital for a total of 10 days. Then, the patient was followed in outpatient clinic weekly for a total of 4 weeks. She was completely asymptomatic with no new issues since discharge.

S3549 A Peculiar Complication of Diabetic Ketoacidosis (DKA) Secondary to Pneumomediastinum: Spontaneous Pneumorrhachis

Introduction: Pneumorrhachis is the presence of free air surrounding the dura matter within the spinal canal. It was first reported by Gordon et al in 1977 and the actual term was coined in 1987 by Newbold et al. Spontaneous pneumorrhachis with extensive pneumomediastinum is a rare but self-limiting condition. We present a unique case of spontaneous pneumorrhachis secondary to pneumomediastinum. Case Description/Methods: A 20-year-old male with a history of Type 1 diabetes mellitus who presented with a two-day history of sudden onset of shortness of breath and retrosternal chest pain. He also reported nausea and multiple episodes of non-bloody, non-bilious emesis over the last two days prior to presentation. He denied fever, cough, trauma, or overt signs of GI bleed. He was tachycardiac and tachypneic on arrival. Exam consistent with anterior chest wall and neck subcutaneous emphysema. Labs were significant for blood glucose 450 with bicarbonate of 8 and an elevated anion gap. He was admitted to the ICU for the management of diabetic ketoacidosis. CXR showed extensive pneumomediastinum. CT chest showed pneumomediastinum with chest wall and neck subcutaneous emphysema. It also showed an important finding of pneumorrhachis. Barium esophagram showed no evidence of esophageal perforation in this patient with pneumomediastinum. No surgical intervention was warranted. Pt was monitored in the ICU, however unfortunately he left against medical advice prior to further investigation. He reported doing well on clinic follow up. Discussion: Pneumorrhachis represents an asymptomatic, radiological finding that is diagnosed with increasing prevalence due to the advancement in radiological techniques and modalities. Spontaneous pneumomediastinum (SPM) is a rare complication of DKA. Bouts of emesis and Kussmaul breathing in diabetic ketoacidosis have been postulated to cause alveolar rupture due to increased intra-alveolar pressure that eventually reaches the spinal canal. The most dangerous differential diagnosis of SPM is Boerhaave’s syndrome that should be excluded with contrast-swallow studies, especially in the setting of vomiting. Treatment is usually conservative since patients are asymptomatic and air is spontaneously resorbed. This case reflects the importance of keeping a differential of spontaneous pneumorrhacis as an important yet subtle complication of DKA.Figure 1.: Extensive pneumomediastinum in the anterior middle and posterior compartment with air extending to the spinal canal and posterior soft tissues.

Bowel Perforation Presenting as Head and Neck Subcutaneous Emphysema.

This patient with Crohn's disease underwent endoscopic balloon dilatation of an ileocolic stricture, and shortly thereafter developed subcutaneous emphysema in the soft tissues of her face, neck, and chest wall. Clinical evaluation and imaging revealed peritonitis from perforated bowel. She underwent laparotomy and bowel resection and recovered well. Subcutaneous emphysema in the head and neck from perforated bowel is a rare but recognized presentation of viscus perforation.

Comparative Study Between Haemorrhage and Surgical Emphysema as Complication of Emergency Tracheostomy

Background: Emergency tracheostomy is the commonest surgical intervention performed as lifesaving procedure by ENT surgeons on patients in emergency room of ENT and ICU. Several operative and postoperative complications have been reported after tracheostomy including fatal hemorrhage. Massive subcutaneous neck emphysema occurred because ventilation started at the time when the hemorrhage was not completely managed and the tracheal tube was not fully secured.
 Objective: This study was conducted to compare haemorrhage and surgical emphysema as complication of emergency tracheostomy among patients admitted in Department of ENT and Head-Neck Surgery in Dhaka Medical College & Hospital.
 Methods and Materials: This was a Cross Sectional Study conducted in the ENT and Head- Neck Surgery Department, Dhaka Medical College Hospital from July 2015 to June 2016. A total of 90 patients were included who fulfilled the selection criteria. Non probability convenient sampling was used to collect data. Statistical analysis was done by SPSS version 21.
 Results: Mean± SD of the study subjects was 49.84±17.4 years with most patients belonged to 40-79 years age group. 28.9% patients had habit of smoking and betel nut chewing. (48.9%) patients suffered from Ca larynx. Out of 90 tracheostomy patients, 40(44.4%) patients had had different complications including haemorrhage (13.3%), surgical emphysema (10%), haemorrhage with surgical emphysema (6.7%), tube blockage (3.3%), wound infection (3.3%) and injury to local tissue (2.2%). Haemorrhage occurs from anterior jugular vein, middle thyroid veins and thyroid gland and included peroperative haemorrhage (7.8%), immediate post- operative haemorrhage, <24 hours, (4.43%) and late post-operative haemorrhage (1.2%).
 Conclusion: In this study, haemorrhage followed by surgical emphysema and haemorrhage with surgical emphysema were found as major complications following emergency tracheostomy,
 J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 159-163

Pneumomediastinum and Neck Subcutaneous Emphysema after Wisdom Tooth Extraction: A Case Report

常規拔牙後，縱隔腔和頸部皮下肺氣腫是很少見的併發症。這些併發症是在牙科處置過程強制性地將空氣注入結締組織引起的。症狀可能因空氣量注入的多少，空氣注入的位置和感染的有無而有所不同。在大多數情況下，縱隔腔和頸部皮下肺氣腫將會在3-5天內開始吸收消失。本病例報告介紹了一位智齒拔牙後發生縱隔腔和頸部皮下肺氣腫的少見案例。

Boerhaave’s Syndrome: Spontaneous Esophageal Perforation

Boerhaave’s Syndrome: Spontaneous Esophageal Perforation

Atypical Presentation of Iatrogenic Colonic Perforation: A Case Report and Review of Previously Reported Cases

Introduction: Iatrogenic perforation is the most feared complication of colonoscopy and may lead to peritonitis, septic shock with a mortality rate upto 25%. Although most colonic perforations are intraperitoneal, extraperitoneal perforations have also been reported. However, a combination of both is extremely rare. Here we present one such case of colonic perforation along with comprehensive literature review of previously reported cases. Case Presentation: A 41-year-old Caucasian female with Ulcerative colitis (UC) presented with fever, watery diarrhea and lower abdominal pain for two days. She was in septic shock and was treated with IV antibiotics & fluids. CT scan of abdomen showed diffuse colitis and right pyelonephritis. After she became stable, colonoscopy was performed which revealed colitis in the descending and sigmoid colon. Biopsies were consistent with UC. Next day, she developed subcutaneous emphysema of the chest wall. CT chest, abdomen and pelvis revealed large pneumoperitoneum, pneumomediastinum & pneumopericardium. She was found to have transverse colon perforation and underwent subtotal colectomy with end ileostomy. Discussion: Vast majority of iatrogenic colonic perforation are intraperitoneal, however very few cases of extraperitoneal perforation have also been reported. We analyzed the duration of symptom onset, clinical features, imaging findings, site of leak and treatment administered in 31 cases of Extraperitoneal perforation reported in English literature. Incidence of perforation was similar after both diagnostic & therapeutic colonoscopies. More than half of perforations were detected within first hour of procedure. Most common presenting clinical feature was subcutaneous emphysema of neck, face or upper chest followed by abdominal pain and dyspnea. Few patients remained asymptomatic. Most common site of perforation was recto-sigmoid followed by cecum. Pneumomediastinum was the most common radiological finding followed by pneumothorax and pneumopericardium. More than half of the patients were treated conservatively while rest needed operative management. Conclusion: Physicians should be cognizant of the possibility of extraperitoneal perforation after colonoscopy. Classical abdominal pain may be absent in majority of cases. Colonic perforation should be considered when a patient presents with facial swelling, chest pain &/or shortness of breath post colonoscopy, as early recognition results in better prognosis.Figure 1Figure 2

Laparoscopic fundoplication for gastroesophageal reflux disease-related cough: a report of 70 cases

To investigate the efficacy and safety of laparoscopic fundoplication for gastroesophageal reflux disease (GERD)-related cough. Retrospective review of 70 patients with GERD-related cough who received laparoscopic fundoplication in GERD Department of The Second Artillery General Hospital during June 2008 to June 2013 was carried out. GERD-related symptoms (reflux, heartburn, cough, expectoration, globus sensation and hoarseness) before and after surgery were compared through questionnaire, and the symptom remission rate (preoperative symptom score - postoperative symptom score)/preoperative symptom score×100%) was calculated. Complication morbidity and satisfaction degree of patients were investigated. The GERD-related symptom scores of regurgitation, heartburn, cough, expectoration, globus sensation and hoarseness all significantly decreased (all P<0.01) after the anti-reflux laparoscopic fundoplication, with the corresponding symptom remission rates as (79.4±23.2)%, (82.0±21.5)%, (72.2±28.5)%, (62.6±28.9)%, (76.1±31.5)% and (70.8±39.3)% respectively. No major complication and death occurred. Five cases (7.1%) had pneumoperitoneum-related chest or neck subcutaneous emphysema, 17 cases (24.3% ) had various degree of early and late dysphagia, 6 cases (8.6%) had increased flatus and 2 cases had bloating after surgery. All the complications could be cured by appropriate treatment. Among all the patients, 16 cases (15.7%) felt very satisfied, 37 cases (52.9%) felt satisfied, 11 cases (15.7%) felt acceptable, 4 cases (5.7%) felt unsatisfied and 2 cases felt very unsatisfied with the surgery. Laparoscopic fundoplication is safe and effective for GERD-related cough, with quite high satisfaction degree form patients.

Subcutaneous Emphysema following Emergent Surgical Conventional Tracheostomy.

In maxillofacial surgery, tracheostomy is indicated in congenital, inflammatory, oncologic, or traumatic respiratory obstruction. In traumatic cases, however, it is sometimes hard to implement. We describe subcutaneous emphysema following emergent surgical conventional tracheostomy performed after stab injury to the floor of the mouth. We analyze the course that led to this complication and discuss suggestions on how to avoid it. In addition, we review the literature to improve our knowledge and practice regarding this entity. Massive subcutaneous neck emphysema occurred because ventilation started at the time when the hemorrhage was not completely managed and the tracheal tube was not fully secured. In traumatic cases with profound bleeding, hemorrhage management must be performed carefully. The recommendation not to ventilate until the hemorrhage is completely managed should be observed.

Spontaneous pneumomediastinum with a rare presentation.

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.

Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoscrotum: unusual complications of acute perforated diverticulitis.

Pneumomediastinum, and subcutaneous emphysema usually result from spontaneous alveolar wall rupture and, far less commonly, from disruption of the upper airways or gastrointestinal tract. Subcutaneous neck emphysema, pneumomediastinum, and retropneumoperitoneum caused by nontraumatic perforations of the colon have been infrequently reported. The main symptoms of spontaneous subcutaneous emphysema are swelling and crepitus over the involved site; further clinical findings in case of subcutaneous cervical and mediastinal emphysema can be neck and chest pain and dyspnea. Radiological imaging plays an important role to achieve the correct diagnosis and extension of the disease. We present a quite rare case of spontaneous subcutaneous cervical emphysema, pneumomediastinum, and pneumoretroperitoneum due to perforation of an occult sigmoid diverticulum. Abdomen ultrasound, chest X-rays, and computer tomography (CT) were performed to evaluate the free gas extension and to identify potential sources of extravasating gas. Radiological diagnosis was confirmed by the subsequent surgical exploration.

Hypopharyngeal laceration with prevertebral dissection mimicking oesophageal perforation

Figure 1: (A) Chest radiography revealed a 1.5-cm radio-opaque density at the level of the T4-5 vertebrae. (B and C) Chest computed tomography demonstrated bilateral neck subcutaneous emphysema and pneumomediastinum with a tubular structure, 15 cm in length, in the cervical and upper thoracic oesophagus. (D) The upper posterior mediastinal pleura were opened, and a ballpoint pen was found between oesophagus and vertebral body.

Subcutaneous emphysema: An unusual presentation of an unsuspected foreign body bronchus in an adult patient

Foreign body in airway is common in children but extremely rare in adults. Here, we are presenting a case report of an adult patient with an unsuspected foreign body in the airway who presented unusually as widespread subcutaneous emphysema in neck. We did an extensive review of literature on this topic but could find only few cases with similar clinical presentation of asymptomatic inhaled foreign body in adults. This case underlines the fact that airway foreign bodies can have extremely unusual presentations and only a high degree of clinical suspicion can clinch the diagnosis. This case is being reported for its unusual presentation and its rarity.

Chest Injury - Hockey

HISTORY: A healthy 43 year-old male is cross checked in the back while playing in recreational hockey, causing immediate pain to his back and left posterior ribs. He is unable to continue playing. During the night, he notices swelling of his neck and face. The following day, the swelling has decreased, but he continues to complain of severe back and rib pain. He also notices a change in his voice. He denies shortness of breath or abdominal pain. He drives himself to the local community Emergency Department. PHYSICAL EXAMINATION: Patient is alert and oriented with all vital signs within normal limits and oxygen saturation of 99% on room air. He grades his pain at 8 of 10. Head is atraumatic and neck has subcutaneous emphysema. Left lateral ribs are tender at approximately #6, 7 and 8. Lungs are clear and equal bilaterally, but patient is splinting. Abdomen is soft and non-tender with no hepato-splenomegaly or tenderness. Patient has subcutaneous emphysema in neck, face, left shoulder and left chest. The remainder of exam is unremarkable. DIFFERENTIAL DIAGNOSIS: Pneumothorax, Pneumomediastinum, Tracheo-bronchial disruption, Rib fractures, Pulmonary contusion, Splenic injury TEST AND RESULTS: Chest X-ray: pneumomediastinum and subcutaneous emphysema. Soft Tissue Neck X-ray: subcutaneous emphysema. Chest, Abdomen, Pelvis CT scan: Pneumomediastinum, Pneumothorax, Fracture of rib # 6, no aortic dissection or hematoma, no pleural effusion, no pericardial effusion, no solid organ injury. Esophagram: no perforation FINAL WORKING DIAGNOSIS: Pneumothorax, Pneumomediastinum, Fracture rib, Subcutaneous emphysema TREATMENT AND OUTCOMES: 1. Chest tube to decompress pneumothorax 2. Admitted to Trauma service 3. Chest tube removed day 3, patient discharged from hospital day 4 4. Follow up chest x-ray on day 24 and 52 show fully expanded lung 5. Permitted to return to hockey day 52

Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury

A case of difficult intubation in a patient with cervical spinal cord injury with diffuse idiopathic skeletal hyperostosis (DISH) is described. The trachea could not be intubated with a videolaryngoscope, and successful intubation was achieved with a laryngeal mask airway device (LMAD) and a fibreoptic bronchoscope (FOB). A 65-yr-old male developed sudden tetraplegia after a fall. Initial attempts at securing his airway were unsuccessful with a videolaryngoscope, but success was achieved with a LMAD and a FOB. Diagnostic imaging revealed no cervical spine fracture but demonstrated severe airway distortion from DISH and a spinal cord contusion accounting for his tetraplegia. Subcutaneous neck emphysema likely secondary to difficult intubation was also identified, but it did not result in additional morbidity. Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace.

後腹膜鏡下腎尿管全摘除術後に気道閉塞を伴う喉頭浮腫をきたした１例

A 76-year-old woman with right renal pelvic cancer underwent a laparoscopic nephroureterectomy via a retroperitoneal approach. During the 300 minutes of CO2 insufflation, arterial blood pressure, temperature, and oxygen saturation were stable, whereas the end-tidal CO2 (ETCO2) gradually increased and reached a peak of 55 mmHg. Her arterial blood gas analysis suggested acute respiratory acidosis. She developed hypercapnia in spite of controlled hyperventilation in response to the increasing ETCO2. Skin crepitus was extending into the neck and face from the operative site. A portable chest radiograph taken postoperatively showed pneumomediastinum and extensive subcutaneous emphysema of neck and chest wall. Laryngoscopy revealed grossly emphysematous pharyngeal tissues preventing direct vocal cord visualization. Her airway was appeared to be totally occluded by markedly edematous laryngeal tissues. As a leak sound around the tracheal tube was not heard after deflation of the tube cuff, her pharyngeal swelling was suspected to be severe and tracheal extubation during the operation was postponed. When cervicofacial emphysema occurs intraoperatively, we recommend that laryngoscopy should be performed before tracheal extubation to avoid potential airway obstruction from associated pharyngeal emphysema.

Chest Pain–Swimming

2032 HISTORY: A 15-year-old competitive swimmer presented to Mayo Clinic with a 24-hour history of sub-sternal chest pain with deep inspiration, associated with anterior neck pain. Onset was during the previous day's training session. The patient was swimming underwater three consecutive 25-meter pool lengths, emerging to take very short breaths, then resuming the described swimming exercise. He developed chest discomfort sub-sternally, and soon thereafter developed neck discomfort. He described this as fullness, as well as a sharp pain in the tracheal region. He had pain with flexion and rotation of the neck. With deep inspiration, he would have a dull sub-sternal ache. Within several hours, his voice changed to a higher pitch. Associated symptoms included mild anxiousness, but he denied shortness of breath. No prior episodes. PHYSICAL EXAM: Examination of the neck revealed pain anteriorly with rotation, flexion and extension. Palpation revealed crepitus in the thyroid region tracking along the trachea. Examination of the heart revealed regular rate and rhythm. No gallops, rubs or murmurs. Examination of the chest revealed no subcutaneous emphysema. Lungs were clear to auscultation bilaterally. However, at the posterior apices, there was a faint popping sound, which cleared. No wheezes were noted. DIFFERENTIAL DIAGNOSIS: Pneumomediastinum Pneumothorax Pneumopericardium Upper respiratory infection Reactive airway/allergic reaction Cervical injury Myocardial infarction/cardiac disease Gastroesophageal Reflux Disease Esophageal Spasm TEST AND RESULTS: Chest x-ray: spontaneous pneumomediastinum with subcutaneous emphysema of the soft tissues in the neck. No pneumothorax or acute changes in the lung fields. Heart size was normal. Neck x-rays: showed deep cervical soft tissue emphysema. Chest CT scan four days after initial chest x-ray: remarkable only for very subtle evidence of residual free air. FINAL/WORKING DIAGNOSIS: Spontaneous pneumomediastinum, with secondary anterior neck subcutaneous emphysema, from extreme breath-holding technique. TREATMENT AND OUTCOMES: Refrain from athletic activities until symptoms of chest discomfort resolve. Repeat chest x-rays must appear normal prior to resumption of swimming. Chest x-ray sequence on day one and day five revealed Saturday pneumomediastinum rapidly resolving. Parallel clinical course. Patient returned successfully to competitive swimming in ten days. Instructed to refrain from utilization of above breathing maneuver. No known recurrence to date.