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Subcutaneous and retropharyngeal emphysema following dental restoration: An uncommon complication
CASE REPORT dental restoration, complications, emphysema; emphysema, following dental restoration
Subcutaneous and Retropharyngeal Emphysema Follrowing Dental Restoration: An Uncommon Complication A case of subcutaneous and retropharyngeal emphysema following a dental restoration zs presented. The patient complained of swelling, tenderness, and a "crackling feeling" of her right face and neck, as well as pcan m the back of her throat. Radiographs confirmed the diagnosis of interstitial air emphysema. The etiology of this unusual complication was the compressed air Used in modern dental drills and syringes. Treatment consists of reassurance, observation, and prophylactic antibiotics. [Bavinger IV: Subcutaneous and retropharyngeal emphysema following dental restoration: An uncommon complication. Ann Emerg Med 11:371-374, July 1982.]
INTRODUCTION Dental instruments powered by compressed air have been in common use for two decades. The frequency of their use, and the paucity of reported complications, is evidence of their relative safety. Complications, when they occur, are usually benign .la However, several serious sequelae have been described. 48 Reported is a case Of subcutaneous and retropharyngeal emphysema following a dental restoration. Etiology, differential diagnosis, and treatment are discussed, accompanied by a brief review of the literature.
James V. Bavinger, MD Dearborn, Michigan From the Department of Emergency Medicine, HenrY Ford Hospital - Fairlane Division, Dearborn, Michigan, Address for reprints: James V. Bavinger, MD, Department of Emergency Medicine, Henry Ford Hospital- Fairlane, 19401 Hubbard Drive, Dearborn, Michigan 48126.
CASE REPORT The patient, a 49-year-old woman, presented 3 hours after undergoing a porcelain amalgam restoration to a lower right cuspid. Although the records were unavailable, it was subsequently learned that 2% xylocaine with 1:100,000 epinephrine had been used for the right mandibular block. Ritter dental instruments employed included the air turbine drill to remove carious material and the air syringe to intermittently dry and clean the operative site. The instruments were powered by compressed air at 30 pounds per square inch. The patient complained of tingling about her right periorbital area during surgery, but no abnormal swelling or other discomforting sensations were noted by the patient or her dentist. Shortly after retuming home, the patient began to notice swelling of her right face and neck with tendemess increasing as the mandibular block wore off. This discomfort also involved the back of her throat. T h e swelling seemed to gradually increase and was noted to be "crackly." The patient became increasingly apprehensive that her throat was going to "close off" and, her dentist's office now closed, she came to the emergency department. Initial vital signs were as follows: temperature, 36.6 C orally; blood pressure, 128/78 m m Hg; pulse, 92 beats/minute; and respirations, 30. The patient was moderately anxious. The right side of her face, including the periorbital, preauricular, zygomatic, mandibular, and submental regions, as well as the right neck, anterior to the stemodeidomastoid muscle, extending to the clavicle in/eriorly, and crossing the midline trachea, were swollen and crepitant to palpation. A flesh porcelain amalgam was noted at the bucco-gingival margin of a lower right cuspid. The gingiva itself was moderately edematous, but the remainder of the oral cavity and posterior oropharynx vcere normal. TM
11:7 July 1982
Annals of Emergency Medicine
371/45
EMPHYSEMA Bavinger
Fig. 1. PA (A) and lateral (B) soft tissue films of neck. Note retropharyngeal and subcutaneous emphysema of right neck and mandibular area extending past the midline.
The trachea was in the midline, carotid pulses were normal, and no stridor was detected. The chest was without deformity or crepitus, and breath sounds were equal and clear bilaterally without wheezes. The cardiac exa m i n a t i o n was n o r m a l ; notably, "Hamman's crtmch" was absent. The remainder of the physical examination was within normal limits. The patient was not hoarse, nor was there any nasal flaring or chest wall retraction. She was taken immediately to the radiology department Where chest films and soft tissue films of the neck revealed interstitial air emphysema of the retropharynx, right face, and neck (Figures 1 and 2). The airway was patent, and no other abnormalities were evident. Consukation with an oral surgeon was obtained. It was his impression that the patient was suffering from s u b c u t a n e o u s and retropharyngeal emphysema as a consequence of compressed air being introduced into the soft tissues at the operative site during her dental restoration. The patient Was admitted to the oral surgery service for observation. Potassium penicillin, 5 0 0 m g PO qid, was administered. She was placed on a liquid diet, and codeine phosphate, 30 to 60 mg IM, was administered every 4 hours as needed for pain. The patient remained stable. At no time did she manifest stridor, retractions, or dysphonia. Her diet was well tolerated and advanced to regular foodsl Swelling and crepitus gradually diminished and the patient was discharged 4 days after admission with d#ht facial swelling and tingling which gradually resolved.
DISCUSSION T h e occurrence of subcutaneous emphysema (SCE) following a dental procedure is an infrequent but well documented phenomenon. In 1900, Tumbull 1 reported a case Of ',traumati c emphysema" in a bugler subsequent to a dental extraction. Shovelton 2 reviewed 45 cases of SCE associated with dental operations, and reported no serious complications. In 1967, Barber and Bums s remarked that SCE was an "unimportant and un46/372
c o m m o n clinical complication . . . usually without danger." Several reports in the literature disagree with this conclusion. Feinstone 4 reported a case of infected SCE resulting from the use of a pressurized dental device. Quisling et al s noted otalgia, eustachian tube dyshmction, and temporary hearing loss in a patient who developed SCE after an amalgam restoration. McGrannahan 6 discussed a patient with dysphagia, dysphonia, and dyspnea as a result of retropharyngeal and superior mediastinal emphysema caused by an air turbine dental drill. Sandler et al 7 presented a case of p n e u m o p e r i t o n e u m , pneumomediastinum, and pneumopericardium following a simple dental extraction. Finally, Rickles and Joshi s postulated that an air embolus caused the death Annals of Emergency Medicine
of a patient undergoing root canal work. They were able to produce this effect experimentally in dogs. The development of interstitial air emphysema (subcutaneous, retropharyngeal, mediaStinal, etc) following a dental procedure has multiple etiologies with a final common p a t h w a y - air dissection into various soft tissue planes. Tumbull's bugler, 1 by the act of "sounding off," raised his intraoral pressure and forced air into the raw socket. Similar results may be expected if coughing, sneezing, blowing the nose, or vomiting follow a recent extraction. 5,9 If hydrogen peroxide is used to prepare the operative site, liberated oxygen may percolate into surrounding s u b c u t a n e o u s tissue, causing emphysema) Hayduk et aP ° speculated that air deflected from the
11:7 July 1982
lactic antibiotics, usually penicillin 9'12'14'16 or tetracycline, 13 are recommended. Analgesics and local heat applications are supportive. Need for hospitalization varies with degree of patient discomfort, infection, or airway compromise. There is no reported case of pneumothorax, pericardial tamponade, or obstructed airway resulting from the use of dental instmments. In Sandler's case, 7 pneumoperitoneum was partially resolved by paracentesis, with "marked improvement." All patients should be cautioned against blowing the nose or playing wind instruments post dental procedures.
SUMMARY Subcutaneous and retropharyngeal emphysema following dental procedure usually results from the compressed air which powers modem dental instruments. Symptomatology is typical and diagnosis should not be difficult. Several complications may develop as a result, but to date airway obstruction has not been described. Treatment is based on reassurance, observation, and prophylactic antibiotics. Hospitalization is usually not required. Patients should be cautioned against those maneuvers which tend to raise intra-oral pressure. Complete resolution may be expected within one week. drill entered her patient's maxillary sinus by way of the nose, diffused through the soft maxillary bone, and caused facial SCE. Home use of waterjet spray devices for oral hygiene is another recognized cause of S E E . 4 T h e m o s t o f t e n c i t e d offende r s 3'5'6'9'11"16 a r e the compressed air dental syringe and the air turbine dental drill. Both operate at pressures of 20 to 30 pounds per square inch. The former is used to clean and dry operative sites. The bit of the drill rotates at 100,000 to 200,000 rpm, with resultant high temperatures. Although most of the air driving the turbine is vented outside the mouth through the drill handle, a small stream of air and water is focused onto the bit by way of small ports in the drill head. This cooling stream from the drill head and the air jet from the dental syringe are the sources of high pressure air which may enter exposed soft tissue. These compressed air devices came into c o m m o n use during the 1960s and parallel the surge of reports in the 11:7 July 1982
literature of complications from their use. Once the pressurized air has access to traumatized tissue, it dissects subperiosteally or through loose areolar connective tissue to the various fascial planes of the face and neck. 3,s'll From the submandibular space this air gains access to the retropharynx, and subsequently, to the superior and anterior mediastmum. 7'12 Symptoms and signs vary according to amount and location. The onset may be immediate 13 or delayed, as in our case. Progression of the emphysema may occur over several hours. Resolution is expected within 5 to 7 days. 9'14'1s The differential diagnosis of facial and neck swelling following a dental procedure includes allergic reaction to anesthesia, hematoma, and infection, as well as SCE. The presence of crepitus should lead to the correct diagnosis. Although gas gangrene may be a remote consideration, it was not mentioned in any of the articles reviewed. Treatment is conservative. ProphyAnnals of Emergency Medicine
REFERENCES 1. Tumbull A: A remarkable coincidence in dental surgery. Br Med J 1:1131, 1900. 2. Shovelton DS: Surgical emphysema as a complication of dental operations. Br Dent J 102:125, 1957. 3. Barber JW, Burns JB: Subcutaneous emphysema of the face and neck after dental restoration. J A m Dent Assoc 75:167169, 1967. 4. Feinstone T: Infected subcutaneous emphysema: Report of a case. J A m Dent Assoc 83:1309-1311, 1971. 5. Quisling RW, Kanger ~ Jahrsdoerfer RA: Otologic complications following the use of a high-speed air-turbine handpiece. J A m Dent Assoc 94:895-897, 1977. 6. McGrarmahan WW: Tissue space emphysema from an air-turbine handpiece. ] A m Dent Assoc 71:884, 1965. 7. Sandler CM, Libshitz HI, Marks G: Pneumoperitoneum, pneumomediastinum, and pneumopericardium following dental extraction. Radiology 115:539-540, 1975. 8. Pickles NH, Joshi BA: Death from air embolism during root canal therapy. Possible cause in a human and an investigation 373/47
EMPHYSEMA Bavinger
Fig. 2. PA chest film. Note cervical and supraclavicular emphysema. The cardiac silhouette is normal. in dogs. J Am Dent Assoc 67:397-404, 1963. 9. Snyder MD, Rosenberg ES: Subcutaneous emphysema during periodontal surgery: Report of a case. J Periodontol 48:790-791, 1977. 10. Hayduk S, Bennett CR, Mortheim LM: Subcutaneous emphysema after operative dentistry: Report of a case. J Am Dent Assoc 80:1362, 1970. 11. LeRoy NB, Bregman AH: Subcutaneous emphysema, l Am Dent Assoc 76:798-799, 1968. 12. Lloyd RE: A case report of surgical emphysema as a complication in endodontics. Oral Health 67:27-28, 1977. 13. Hunt RB, Sahler OD: Mediastinal emphysema produced by air-turbine dental drills. JAMA 205:101-102, 1968. 14. Asrican P: Accidental subcutaneous surgical emphysema after extraction of the upper tight first molar: Report of a case. J Am Dent Assoc 75:1169, 1967. 15. Geffner I: Subcutaneous facial emphysema following an amalgam restoration. Br Dent J 148:192, 1980. 16. Gaman W: Subcutaneous emphysema during dental treatment. Can Med Assoc J 116:838, 1977.
48/374
Annals of Emergency Medicine
1:7 July 1982
Subcutaneous and Retropharyngeal Emphysema Follrowing Dental Restoration: An Uncommon Complication A case of subcutaneous and retropharyngeal emphysema following a dental restoration zs presented. The patient complained of swelling, tenderness, and a "crackling feeling" of her right face and neck, as well as pcan m the back of her throat. Radiographs confirmed the diagnosis of interstitial air emphysema. The etiology of this unusual complication was the compressed air Used in modern dental drills and syringes. Treatment consists of reassurance, observation, and prophylactic antibiotics. [Bavinger IV: Subcutaneous and retropharyngeal emphysema following dental restoration: An uncommon complication. Ann Emerg Med 11:371-374, July 1982.]
INTRODUCTION Dental instruments powered by compressed air have been in common use for two decades. The frequency of their use, and the paucity of reported complications, is evidence of their relative safety. Complications, when they occur, are usually benign .la However, several serious sequelae have been described. 48 Reported is a case Of subcutaneous and retropharyngeal emphysema following a dental restoration. Etiology, differential diagnosis, and treatment are discussed, accompanied by a brief review of the literature.
James V. Bavinger, MD Dearborn, Michigan From the Department of Emergency Medicine, HenrY Ford Hospital - Fairlane Division, Dearborn, Michigan, Address for reprints: James V. Bavinger, MD, Department of Emergency Medicine, Henry Ford Hospital- Fairlane, 19401 Hubbard Drive, Dearborn, Michigan 48126.
CASE REPORT The patient, a 49-year-old woman, presented 3 hours after undergoing a porcelain amalgam restoration to a lower right cuspid. Although the records were unavailable, it was subsequently learned that 2% xylocaine with 1:100,000 epinephrine had been used for the right mandibular block. Ritter dental instruments employed included the air turbine drill to remove carious material and the air syringe to intermittently dry and clean the operative site. The instruments were powered by compressed air at 30 pounds per square inch. The patient complained of tingling about her right periorbital area during surgery, but no abnormal swelling or other discomforting sensations were noted by the patient or her dentist. Shortly after retuming home, the patient began to notice swelling of her right face and neck with tendemess increasing as the mandibular block wore off. This discomfort also involved the back of her throat. T h e swelling seemed to gradually increase and was noted to be "crackly." The patient became increasingly apprehensive that her throat was going to "close off" and, her dentist's office now closed, she came to the emergency department. Initial vital signs were as follows: temperature, 36.6 C orally; blood pressure, 128/78 m m Hg; pulse, 92 beats/minute; and respirations, 30. The patient was moderately anxious. The right side of her face, including the periorbital, preauricular, zygomatic, mandibular, and submental regions, as well as the right neck, anterior to the stemodeidomastoid muscle, extending to the clavicle in/eriorly, and crossing the midline trachea, were swollen and crepitant to palpation. A flesh porcelain amalgam was noted at the bucco-gingival margin of a lower right cuspid. The gingiva itself was moderately edematous, but the remainder of the oral cavity and posterior oropharynx vcere normal. TM
11:7 July 1982
Annals of Emergency Medicine
371/45
EMPHYSEMA Bavinger
Fig. 1. PA (A) and lateral (B) soft tissue films of neck. Note retropharyngeal and subcutaneous emphysema of right neck and mandibular area extending past the midline.
The trachea was in the midline, carotid pulses were normal, and no stridor was detected. The chest was without deformity or crepitus, and breath sounds were equal and clear bilaterally without wheezes. The cardiac exa m i n a t i o n was n o r m a l ; notably, "Hamman's crtmch" was absent. The remainder of the physical examination was within normal limits. The patient was not hoarse, nor was there any nasal flaring or chest wall retraction. She was taken immediately to the radiology department Where chest films and soft tissue films of the neck revealed interstitial air emphysema of the retropharynx, right face, and neck (Figures 1 and 2). The airway was patent, and no other abnormalities were evident. Consukation with an oral surgeon was obtained. It was his impression that the patient was suffering from s u b c u t a n e o u s and retropharyngeal emphysema as a consequence of compressed air being introduced into the soft tissues at the operative site during her dental restoration. The patient Was admitted to the oral surgery service for observation. Potassium penicillin, 5 0 0 m g PO qid, was administered. She was placed on a liquid diet, and codeine phosphate, 30 to 60 mg IM, was administered every 4 hours as needed for pain. The patient remained stable. At no time did she manifest stridor, retractions, or dysphonia. Her diet was well tolerated and advanced to regular foodsl Swelling and crepitus gradually diminished and the patient was discharged 4 days after admission with d#ht facial swelling and tingling which gradually resolved.
DISCUSSION T h e occurrence of subcutaneous emphysema (SCE) following a dental procedure is an infrequent but well documented phenomenon. In 1900, Tumbull 1 reported a case Of ',traumati c emphysema" in a bugler subsequent to a dental extraction. Shovelton 2 reviewed 45 cases of SCE associated with dental operations, and reported no serious complications. In 1967, Barber and Bums s remarked that SCE was an "unimportant and un46/372
c o m m o n clinical complication . . . usually without danger." Several reports in the literature disagree with this conclusion. Feinstone 4 reported a case of infected SCE resulting from the use of a pressurized dental device. Quisling et al s noted otalgia, eustachian tube dyshmction, and temporary hearing loss in a patient who developed SCE after an amalgam restoration. McGrannahan 6 discussed a patient with dysphagia, dysphonia, and dyspnea as a result of retropharyngeal and superior mediastinal emphysema caused by an air turbine dental drill. Sandler et al 7 presented a case of p n e u m o p e r i t o n e u m , pneumomediastinum, and pneumopericardium following a simple dental extraction. Finally, Rickles and Joshi s postulated that an air embolus caused the death Annals of Emergency Medicine
of a patient undergoing root canal work. They were able to produce this effect experimentally in dogs. The development of interstitial air emphysema (subcutaneous, retropharyngeal, mediaStinal, etc) following a dental procedure has multiple etiologies with a final common p a t h w a y - air dissection into various soft tissue planes. Tumbull's bugler, 1 by the act of "sounding off," raised his intraoral pressure and forced air into the raw socket. Similar results may be expected if coughing, sneezing, blowing the nose, or vomiting follow a recent extraction. 5,9 If hydrogen peroxide is used to prepare the operative site, liberated oxygen may percolate into surrounding s u b c u t a n e o u s tissue, causing emphysema) Hayduk et aP ° speculated that air deflected from the
11:7 July 1982
lactic antibiotics, usually penicillin 9'12'14'16 or tetracycline, 13 are recommended. Analgesics and local heat applications are supportive. Need for hospitalization varies with degree of patient discomfort, infection, or airway compromise. There is no reported case of pneumothorax, pericardial tamponade, or obstructed airway resulting from the use of dental instmments. In Sandler's case, 7 pneumoperitoneum was partially resolved by paracentesis, with "marked improvement." All patients should be cautioned against blowing the nose or playing wind instruments post dental procedures.
SUMMARY Subcutaneous and retropharyngeal emphysema following dental procedure usually results from the compressed air which powers modem dental instruments. Symptomatology is typical and diagnosis should not be difficult. Several complications may develop as a result, but to date airway obstruction has not been described. Treatment is based on reassurance, observation, and prophylactic antibiotics. Hospitalization is usually not required. Patients should be cautioned against those maneuvers which tend to raise intra-oral pressure. Complete resolution may be expected within one week. drill entered her patient's maxillary sinus by way of the nose, diffused through the soft maxillary bone, and caused facial SCE. Home use of waterjet spray devices for oral hygiene is another recognized cause of S E E . 4 T h e m o s t o f t e n c i t e d offende r s 3'5'6'9'11"16 a r e the compressed air dental syringe and the air turbine dental drill. Both operate at pressures of 20 to 30 pounds per square inch. The former is used to clean and dry operative sites. The bit of the drill rotates at 100,000 to 200,000 rpm, with resultant high temperatures. Although most of the air driving the turbine is vented outside the mouth through the drill handle, a small stream of air and water is focused onto the bit by way of small ports in the drill head. This cooling stream from the drill head and the air jet from the dental syringe are the sources of high pressure air which may enter exposed soft tissue. These compressed air devices came into c o m m o n use during the 1960s and parallel the surge of reports in the 11:7 July 1982
literature of complications from their use. Once the pressurized air has access to traumatized tissue, it dissects subperiosteally or through loose areolar connective tissue to the various fascial planes of the face and neck. 3,s'll From the submandibular space this air gains access to the retropharynx, and subsequently, to the superior and anterior mediastmum. 7'12 Symptoms and signs vary according to amount and location. The onset may be immediate 13 or delayed, as in our case. Progression of the emphysema may occur over several hours. Resolution is expected within 5 to 7 days. 9'14'1s The differential diagnosis of facial and neck swelling following a dental procedure includes allergic reaction to anesthesia, hematoma, and infection, as well as SCE. The presence of crepitus should lead to the correct diagnosis. Although gas gangrene may be a remote consideration, it was not mentioned in any of the articles reviewed. Treatment is conservative. ProphyAnnals of Emergency Medicine
REFERENCES 1. Tumbull A: A remarkable coincidence in dental surgery. Br Med J 1:1131, 1900. 2. Shovelton DS: Surgical emphysema as a complication of dental operations. Br Dent J 102:125, 1957. 3. Barber JW, Burns JB: Subcutaneous emphysema of the face and neck after dental restoration. J A m Dent Assoc 75:167169, 1967. 4. Feinstone T: Infected subcutaneous emphysema: Report of a case. J A m Dent Assoc 83:1309-1311, 1971. 5. Quisling RW, Kanger ~ Jahrsdoerfer RA: Otologic complications following the use of a high-speed air-turbine handpiece. J A m Dent Assoc 94:895-897, 1977. 6. McGrarmahan WW: Tissue space emphysema from an air-turbine handpiece. ] A m Dent Assoc 71:884, 1965. 7. Sandler CM, Libshitz HI, Marks G: Pneumoperitoneum, pneumomediastinum, and pneumopericardium following dental extraction. Radiology 115:539-540, 1975. 8. Pickles NH, Joshi BA: Death from air embolism during root canal therapy. Possible cause in a human and an investigation 373/47
EMPHYSEMA Bavinger
Fig. 2. PA chest film. Note cervical and supraclavicular emphysema. The cardiac silhouette is normal. in dogs. J Am Dent Assoc 67:397-404, 1963. 9. Snyder MD, Rosenberg ES: Subcutaneous emphysema during periodontal surgery: Report of a case. J Periodontol 48:790-791, 1977. 10. Hayduk S, Bennett CR, Mortheim LM: Subcutaneous emphysema after operative dentistry: Report of a case. J Am Dent Assoc 80:1362, 1970. 11. LeRoy NB, Bregman AH: Subcutaneous emphysema, l Am Dent Assoc 76:798-799, 1968. 12. Lloyd RE: A case report of surgical emphysema as a complication in endodontics. Oral Health 67:27-28, 1977. 13. Hunt RB, Sahler OD: Mediastinal emphysema produced by air-turbine dental drills. JAMA 205:101-102, 1968. 14. Asrican P: Accidental subcutaneous surgical emphysema after extraction of the upper tight first molar: Report of a case. J Am Dent Assoc 75:1169, 1967. 15. Geffner I: Subcutaneous facial emphysema following an amalgam restoration. Br Dent J 148:192, 1980. 16. Gaman W: Subcutaneous emphysema during dental treatment. Can Med Assoc J 116:838, 1977.
48/374
Annals of Emergency Medicine
1:7 July 1982