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Emphysema of Neck Following Oral Cavity
Trauma- Case Report
Acosta Boett Ligia3*, Marian Fuentes1, Bastidas Yanet2, Arrieta Noraima2, Rodríguez Olira1, Rivas Carlos1 and Delgado Beatriz1
1Residente del Postgrado de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
2Adjunto del Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
3Jefe de Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, South America
Submission: February 16, 2017; Published: March 03, 2017
*Corresponding author: Acosta Boett Ligia, Jefe de Servicio de Otorrinolaringología. Hospital de Niños “Dr. José Manuel de los Ríos”, Vicepresidenta de la Junta Directiva SVORL, Venezuela, South America Email:email@example.com
How to cite this article: Acosta B L, Marian F, Bastidas Y, Arrieta N, Rodríguez O, et, al. Emphysema of Neck Following Oral Cavity Trauma- Case Report.
Glob J Oto 2017; 4(3): 555639. DOI: 10.19080/GJO.2017.04.555639
Introduction: Emphysema is a swelling caused by the penetration of air or gas in the subcutaneous or submucosal tissues. Etiology can betraumatic, iatrogenic or spontaneous. When the anatomic site involved committed neck spaces, you can dissect extensive muscle-fascial planes, like the deep spaces of the neck and mediastinum. The clinic is variable, it depends on the location involved, can manifest as a slight sore throat, respiratory distress, stridor or snoring, chest pain if pneumomediastinum, causing significant symptoms of hemodynamic and respiratory decompensation.
Case: Male 06 years old, born and from the town, who after oral trauma with blunt object (umbrella) School presents oral cavity bleeding, sore throat and progressive dysphagia drooling with cervical pain and functional limitation neck movements; without respiratory distress. Rx neck and chest is made where retropharyngeal emphysema reaching pericardium through the mediastinum evidence. In CT scan of neck extension thorax air is evident in paravertebral spaces, bilateral parapharyngeal and towards the base of the neck with small bubbles dissect the plane of the thyroid gland, vascular structures and predominance of left upper mediastinum level, reason by which it is entered with continuous monitoring of respiratory and internal environment, prophylactic antibiotics and analgesia, evolving satisfactorily, without complications.
Conclusion: Emphysema in neck deep spaces are rare. In most cases spontaneously reabsorbed emphysema, however, the patient must be kept under observation to reduce complications; Likewise administration of analgesia and prophylactic antibiotic therapy.
The term emphysema comes from the Greek word ‘‘emphysan’’ and means ‘‘to blow inside’’. Emphysema is a swelling produced by the penetration of air or gas into the subcutaneous or submucosal tissues. According to the medical record of the Dominican Republic, I reported an incidence of 0.8 per 1000 inhabitants, with a male prevalence between the ages of 3 to 70 years. The etiology of emphysema can be traumatic of the blunt, punctured, and punctured type involving structures at the neck (trachea, larynx, esophagus) and thorax; The most common cause is maxillary surgery and dental procedures (extractions, endodoncias and cleanings), the most outstanding being the extraction of the 3rd molar, difficult intubations, spontaneous tonsillectomy Such as Boerhaave Syndrome, seizures, inflating a balloon, all these causes include abnormal air pressures. When the compromised anatomical site involves the spaces of the neck, it can dissect extensive muscular-aponeurotic planes, such as the deep spaces of the neck and the mediastinum [1-6].
The neck has fascias that define the spaces that limit to some extent the spread of infections and tumors. These spaces include the retropharyngeal space that is previously delimited by the buccopharyngeal fascia and later by the prevertebral fascia, extending from the base of the skull to the anterior mediastinum. The clinical presentationis variable, depending on the place involved, may manifest as slight odynophagia, respiratory distress, stridor or snoring, retrosternal pain in case of pneumomediastinum, causing important hemodynamic and respiratory decompensation symptoms. The most common initial diagnostic method is the chest x-ray, where the presence of air can be observed by dissecting the deep spaces of the neck
that may even extend to the mediastinum, as well as a CT scan
of the neck with an extension to the neck which is more specific,
it is possible to visualize the location, extension and precise
characteristics of the lesion [7-10].
The behavior to be followed will depend on the extent
of the emphysema and its severity, since in most cases it is
spontaneously resorbed. Conservative therapy based on internal
and respiratory monitoring, anti-inflammatory, and prophylactic
antibiotic therapy for gram (+) germs mainly, this issue has
been discussed by different authors, without reaching a total
consensus. When symptoms are more severe, a multidisciplinary
approach should be performed with the services associated
with complications, eg: pulmonology, cardiology, chest surgery,
even in more extreme cases. General surgery in the case of
pneumoperitoneum, Dr. Petersilka in the year 2011, in its
publication in the journal of the Spanish Society of Periodontics
and Osseointegration, poses the following algorithm for the
management of cervical emphysema.
A 6-year-old male, natural and from the locality, who after
oral trauma with a blunt tip (umbrella) has oral cavity bleeding,
odynophagia and dysphagia. Progressive, sialorrhoea, with pain
in cervical region and functional limitation in movements of the
neck; Without respiratory difficulty.
Stable clinical conditions: examination of ear and nose
revealed no abnormality.
Bifid uvula with blood remains. Tonsils grade III / IV.
Oropharyngeal wall without lesions.
Neck: short without volume increase, central trachea,
thyroid 0 degree. Erythema in right lateral triangle is
evident in posterior border of the ECM, as well as pain to
Cardiopulmonary: normoexpansible symmetrical
thorax, audible MV in both pulmonary fields without
aggregates. RsCsRsnormofonéticos no murmurs.
Nasofibrolaryngoscopy is carried out where no lesion or
stigma of the same is evidenced, or hematic remains. Rx of
the neck and thorax where retropharyngeal emphysema is
found that reaches the pericardium through the mediastinum
(Figures 1 & 2). In computerized tomography of the neck
with chest extension air is evident in paravertebral, bilateral
parapharyngeal spaces and towards the base of the neck with
small bubbles that dissect the plane of the thyroid gland, vascular
structures predominating on the left side and at the level of the
upper mediastinum (Figures 3-6).
It is evaluated by the service of Thorax and Pneumonology
Surgery who in view of the findings in the imaging studies,
the diagnosis of: Trauma of oral cavity complicated with
parapharyngeal emphysema and pneumomediastinum; And
antibiotic prophylaxis with ampicillin / sulbactan 100mg / kg
/ day and anti-inflammatory with Dexamethasone 0.6mg / kg
/ day for 72 hours and ketoprofen 1mg / kg / dose, oxygen By
mask;satisfactorily, without complications.
Report that subcutaneous emphysema in the neck is not
infrequent in our specialty. In many spontaneous, accidental
or surgical situations air can appear in the cervical spaces,
being the most frequent cause the maxillary surgeries and
dental procedures (extractions, endodoncias and cleanings),
however the progression of air or gas towards the mediastinum
is exceptional. The behavior for this entity is determined
according to the patient’s symptoms and extent of emphysema,
however, emphysema in most cases is resolved spontaneously.
The most commonly used behavior is wet oxygen to accelerate
air reabsorption and increase air pressure. O2 in the tissue.
Analgesia to reduce pain; The use of prophylactic antibiotics is
a topic of debate, although there are no detailed trials of it, the
use of these to prevent possible infections, recommend oral or intravenous antibiotics as derivatives of penicillin (amoxicillin,
ampicillin), cephalosporins or clindamycin [10-14].
Our clinical case coincides as regards etiology (traumatism)
and clinical evidence, although the pathogenesis of presentation
is different since the pneumomediastinum is caused by
subcutaneous emphysema by disruption of the oropharyngeal
membrane allowing the passage of ambient air into the
retropharyngeal space producing . The dissection of this
until reaching the upper mediastinum, which is achieved due to
the pressures of ambient air that are greater than the internal
pressures. Also the tools used for diagnosis and conduct are in
accordance with those recommended by this academy.
Emphysema in deep spaces of the neck, are rare. In most cases
emphysema is spontaneously reabsorbed, however, the patient
should be kept under observation to reduce complications; As
well as administration of analgesia and prophylactic antibiotic