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Postextraction subcutaneous emphysema
POSTEXTRACTION
SUBCUTANEOUS
Ray Rhymes, Jr., Lieutenant 0. S. Wazal Training
CASE
(DC)
EMPHYSEMA
USNR”
Center, Great Lakes, Ill.
REPORT
A 23.year-old white man was referred to the oral surgery clinic for consultation. The chief complaint was of pain and a palpable bubbling sensation in the subcutaneous tissue of the neck and pectoral regions. H&ory.-On Feb. 1, 1963, the lower right third molar was extracted. The crown of the tooth was badly decayed, and surgical removal of the roots was necessary. A vertical incision for a mucoperiosteal flap had been made in the second molar area. There were no complications during the operative procedure. Upon leaving the office, the patient was “feeling his jaw,” as one often does follow ing an inferior alveolar nerve block. A bubbling sensation was felt in the region of the lower anterior border of the masseter muscle. At 2 A.M. the next day he was awakened by severe pain in the cervical and pectoral regions. The same bubbling sensation was now present in these areas. The patient was taken to the medical sick call, and a chest roentgenogram, antibiotics, and analgesics were ordered. He was then referred to the oral surgery clinic.
Fig.
was
L-Intraoral present
view with a pointer showing in the depth of the mcision just
route of entry by the air. A 3 by 3 mm. defect below the second molar (first molar absent).
The opinions or assertions contained herein are those of the author and construed as official or reflecting the views of the Department of the Navy Services at large. *Formerly Senior resident, Oral Surgery Department, Confederate Memorial ter, Shreveport, La. Present address: Dental Dept. Bldg. 600, Adcom, Great Training Center, Great Lakes, Ill. 271
are not to be or the Naval Medical CenLakes Naval
I)IYCUSSION
The development of cervical and pectoral subcutaneous emphysema follow ing exodontia is very rare. R case reported by Kleinmanl in 1961 is almost identical to this one. There are two possibilities to consider with respect to the entrance 01’ aila into the tissues. A positive or negative pressure is needed. The pressures created routinely in the oral cavity serve as an excellent source of positive pressure. However, there are those who believe that reflection of the periosteum from bone in the third molar region may create a sucking action. Although a didactic point, the former possibility seems more plausible. It is believed that, this case is important for other reasons. First, the air could definitely be followed from t,he region of the flap on the buccal surface of the mandible, over the lower border where the facial vessels cross, down the neck (mainly near the anterior border of the sternocleidomastoid muscle), and further into the pectoral region. Thus, t,he anatomic path taken by thr air was evident.
\‘olume 17 Number 2
POSTEXTRACTION
SUBCUTANEOUS
EMPHYSEMA
273
Another factor of importance is the flap design. Normally, the periosteum serves as a fairly good limiting factor for any air that may be introduced between it and bone. If, however, this dense layer of connective tissue is torn or severed below the line of the attached gingivae, then air may gain access to the more superficial loose connective tissue. As evidenced by this case, it is important to avoid deep vertical incisions of the mandibular periosteum (CSpecially in the posterior regions). Healing is also retarded if the incision reaches the depth of the suleus because of movement of the buceinator muscle. Having diagnosed the presence of air in the subcutaneous tissue, one is faced with treatment and prognosis. Treatment should be conservative, and healing time is usually 2 to 4 days. Analgesics are given as necessary for pain. One must consider the possibility of infection, as oral organisms may become pathogenic when implanted into distant tissues. This is especially true if the area was inflamed or if oral hygiene was poor. Depending on the individual case, prophylactic antibiotics are usually indicated. A broad-spectrum drug should be considered primarily, as the danger of penicillin therapy is ever increasing. Finally, one other factor should be considered regarding prognosis. In a recent case report2 it was pointed out that fatalities may occur from gas emboli arising in a subcutaneous site. Subcutaneous oxygen was being used therapeutically in that case, The postmortem examination showed gas embolism of the right side of the heart. The volume of gas used was very large, and this may or may not be a factor to consider. Nevertheless, gas emboli could concievably be a consequence in any case where there is a subcutaneous depot of air or oxygen. SUMMARY
A case of postextraction subcutaneous emphysema has been presented. Mucoperiosteal flap design (especially in the lower molar area) may be a factor to consider with regard to the development of this condition. Pain was the most important sequela in this case. The treatment should be conservative, and the prognosis is usually good. Infection and gas embolism are complications to be considered. REFERENCES
Emphysema After Oral Surgery, J. Oral 1. Kleinman, H. Z.: Subcutaneous and Mediastinal Surg., Anesth. & Hosp. D. Serv. 19: 527! 1961. 2. Peteroffa: Case of Death by Subcutaneous InJection of Oxygen. Stomatologiia. Moscow 5: GS, 1959 (reprinted in J. Am. D. Soe. Anesth. 9: 207-208, November, 1962).
SUBCUTANEOUS
Ray Rhymes, Jr., Lieutenant 0. S. Wazal Training
CASE
(DC)
EMPHYSEMA
USNR”
Center, Great Lakes, Ill.
REPORT
A 23.year-old white man was referred to the oral surgery clinic for consultation. The chief complaint was of pain and a palpable bubbling sensation in the subcutaneous tissue of the neck and pectoral regions. H&ory.-On Feb. 1, 1963, the lower right third molar was extracted. The crown of the tooth was badly decayed, and surgical removal of the roots was necessary. A vertical incision for a mucoperiosteal flap had been made in the second molar area. There were no complications during the operative procedure. Upon leaving the office, the patient was “feeling his jaw,” as one often does follow ing an inferior alveolar nerve block. A bubbling sensation was felt in the region of the lower anterior border of the masseter muscle. At 2 A.M. the next day he was awakened by severe pain in the cervical and pectoral regions. The same bubbling sensation was now present in these areas. The patient was taken to the medical sick call, and a chest roentgenogram, antibiotics, and analgesics were ordered. He was then referred to the oral surgery clinic.
Fig.
was
L-Intraoral present
view with a pointer showing in the depth of the mcision just
route of entry by the air. A 3 by 3 mm. defect below the second molar (first molar absent).
The opinions or assertions contained herein are those of the author and construed as official or reflecting the views of the Department of the Navy Services at large. *Formerly Senior resident, Oral Surgery Department, Confederate Memorial ter, Shreveport, La. Present address: Dental Dept. Bldg. 600, Adcom, Great Training Center, Great Lakes, Ill. 271
are not to be or the Naval Medical CenLakes Naval
I)IYCUSSION
The development of cervical and pectoral subcutaneous emphysema follow ing exodontia is very rare. R case reported by Kleinmanl in 1961 is almost identical to this one. There are two possibilities to consider with respect to the entrance 01’ aila into the tissues. A positive or negative pressure is needed. The pressures created routinely in the oral cavity serve as an excellent source of positive pressure. However, there are those who believe that reflection of the periosteum from bone in the third molar region may create a sucking action. Although a didactic point, the former possibility seems more plausible. It is believed that, this case is important for other reasons. First, the air could definitely be followed from t,he region of the flap on the buccal surface of the mandible, over the lower border where the facial vessels cross, down the neck (mainly near the anterior border of the sternocleidomastoid muscle), and further into the pectoral region. Thus, t,he anatomic path taken by thr air was evident.
\‘olume 17 Number 2
POSTEXTRACTION
SUBCUTANEOUS
EMPHYSEMA
273
Another factor of importance is the flap design. Normally, the periosteum serves as a fairly good limiting factor for any air that may be introduced between it and bone. If, however, this dense layer of connective tissue is torn or severed below the line of the attached gingivae, then air may gain access to the more superficial loose connective tissue. As evidenced by this case, it is important to avoid deep vertical incisions of the mandibular periosteum (CSpecially in the posterior regions). Healing is also retarded if the incision reaches the depth of the suleus because of movement of the buceinator muscle. Having diagnosed the presence of air in the subcutaneous tissue, one is faced with treatment and prognosis. Treatment should be conservative, and healing time is usually 2 to 4 days. Analgesics are given as necessary for pain. One must consider the possibility of infection, as oral organisms may become pathogenic when implanted into distant tissues. This is especially true if the area was inflamed or if oral hygiene was poor. Depending on the individual case, prophylactic antibiotics are usually indicated. A broad-spectrum drug should be considered primarily, as the danger of penicillin therapy is ever increasing. Finally, one other factor should be considered regarding prognosis. In a recent case report2 it was pointed out that fatalities may occur from gas emboli arising in a subcutaneous site. Subcutaneous oxygen was being used therapeutically in that case, The postmortem examination showed gas embolism of the right side of the heart. The volume of gas used was very large, and this may or may not be a factor to consider. Nevertheless, gas emboli could concievably be a consequence in any case where there is a subcutaneous depot of air or oxygen. SUMMARY
A case of postextraction subcutaneous emphysema has been presented. Mucoperiosteal flap design (especially in the lower molar area) may be a factor to consider with regard to the development of this condition. Pain was the most important sequela in this case. The treatment should be conservative, and the prognosis is usually good. Infection and gas embolism are complications to be considered. REFERENCES
Emphysema After Oral Surgery, J. Oral 1. Kleinman, H. Z.: Subcutaneous and Mediastinal Surg., Anesth. & Hosp. D. Serv. 19: 527! 1961. 2. Peteroffa: Case of Death by Subcutaneous InJection of Oxygen. Stomatologiia. Moscow 5: GS, 1959 (reprinted in J. Am. D. Soe. Anesth. 9: 207-208, November, 1962).