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Pneumomediastinum, bilateral pneumothorax, pleural effusion, and surgical emphysema after routine apicectomy caused by vomiting
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British Journal of Oral and Maxillofacial Surgery 46 (2008) 136–137
Short communication
Pneumomediastinum, bilateral pneumothorax, pleural effusion, and surgical emphysema after routine apicectomy caused by vomiting Archita Gulati a,∗ , Andrew Baldwin b , Ian Mc. Intosh c , A. Krishnan d a
General Surgery at Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom Department of Oral Surgery, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom c Department of Surgery, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom d Department of Anaesthesia, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom b
Accepted 20 November 2006 Available online 25 January 2007
Abstract Mediastinal and subcutaneous emphysema may occur after dental and oral surgery as a result of iatrogenic introduction of air or injury to the tracheobronchial tree. We report a patient who developed emphysema and pneumothorax after dentoalveolar surgery, which made diagnosis and management difficult. We suggest that persistent postoperative vomiting caused inhalation of mediastinal and intrathoracic air. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Pneumomediastinum; Emphysema; Vomiting; Dental surgery
Case report A 43-year-old woman had apicectomy of four maxillary teeth under general anaesthesia. She was a smoker and had chronic obstructive airways disease. She had routine fibre optic intubation. As she was slightly drowsy in the recovery room, she was admitted overnight for observation. Three hours after intubation she developed intractable vomiting followed by chest pain, diplopia, and facial and neck swelling. She had a tachycardia (105 beats/min) and respiratory distress, with subcutaneous emphysema over the face, neck, and chest wall. Chest radiograph showed mediastinal air and massive surgical emphysema (Fig. 1). A contrast-enhanced computed tomogram (CT) of the chest and abdomen confirmed mediastinal emphysema and an extensive pneumothorax (Fig. 2). Though there was no ∗ Corresponding author at: Department of Surgery, Christie Hospitals NHS Trust, Wilmslow Road M204 BX, United Kingdom. Tel.: +44 1614468051; fax: +44 1616278774. E-mail address: [email protected] (A. Gulati).
extravasation of contrast, pneumoperitoneum was reported. Because we suspected rupture of the lower end of the oesophagus caused by severe vomiting, she had an exploratory laparotomy after bilateral chest drains had been inserted but this showed nothing untoward. Operative gastroscopy was also within normal limits and showed no oesophageal rupture. She made a slow postoperative recovery and required artificial ventilation for several days. She was discharged a month after her original procedure.
Discussion Air may present suddenly in the neck, subcutaneous tissues, mediastinum, and retroperitoneal soft tissues with no apparent explanation. This warrants urgent investigation. Several mechanisms have been implicated including suppurative infections such as dental abscess or mediastinitis, direct introduction of air after mucosal or cutaneous disruption such as dental procedures; Boerhaave’s syn-
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.11.008
A. Gulati et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 136–137
Fig. 1. Massive bilateral subcutaneous emphysema and mediastinal air (arrow).
137
The mucosa may also be disrupted after a difficult intubation, with injury to the tracheobronchial passages, leading to the rapid onset of emphysema and pneumothorax. However, our patient had no symptoms for several hours after extubation. Mediastinal and intraperitoneal air, as suspected in our patient, can occur in Boerhaave’s syndrome, which is spontaneous rupture of the distal oesophagus as a result of intractable vomiting that causes a sudden rise in intraluminal oesophageal pressure; this prevents the cricopharyngeus muscle from relaxing .5 It presents with chest pain, mediastinitis, effusion, and pneumothorax, and warrants emergency intervention.6 The presence of air at the bases of a hyperinflated lung in a chronically obstructed airway was misinterpreted as pneumoperitoneum on CT, which unfortunately led to an unnecessary operation. Spontaneous pneumothorax also results from barotrauma and has been described during labour,7 sneezing, coughing, and straining at stool, or Valsalva manouvre.1 The most common cause of mediastinal emphysema is alveolar rupture, which has been described by Macklin.8 We think that barotrauma after vomiting was the cause of the pneumomediastinum and subcutaneous emphysema in our patient. We know of only one previous report of vomiting as a cause of pneumothorax and pneumomediastinum.9 References
Fig. 2. Computed tomogram of upper thorax showing surgical emphysema of the soft tissue spaces of the neck, and bilateral pneumothoraces at the apexes of the lungs.
drome or traumatic intubation; or spontaneously after barotrauma.1 Pneumomediastinum and pneumothorax may occur after dental extraction, root canal treatment, or drilling of third molars2 when a high speed air turbine drill is used, or an air-water cooled syringe,3 because the soft tissue spaces of the neck communicate with the mediastinum.4 Air can track from the sublingual and submandibular spaces to the pterygomandibular, parapharyngeal, and retropharyngeal spaces, and then to the mediastinum and pleural spaces. However, the drill used in our case was a surgical air drill (closed system), unlike the air turbine used in dental surgeries for restorative dentistry. This drill had a lower free speed of 0–50,000 revolutions/second. No faults were detected when the equipment was examined postoperatively.
1. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Arch Intern Med 1984;144:1447–53. 2. Sandler CM, Libshitz H, Marks G. Pneumoperitoneum, pneumomediastinum, pneumopericardium following dental extraction. Radiology 1975;115:539–40. 3. Barkdull TJ. Pneumothorax during dental care. J Am Board Fam Pract 2003;16:165–9. 4. Salib RJ, Valentine P, Akhtar S. Surgical emphysema following dental treatment. J Laryngol Otol 1999;13:756–8. 5. Pate JW, Walker WA, Cole FH, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689–92. 6. Bjerke HS. Boerhaave’s syndrome and barogenic injuries of the esophagus. Chest Surg Clin N Am 1994;4:819–25. 7. Turner M, Benton PJ. Three cases of pneumomediastinum - after labour, sneezing and compressed-air diving. J R Soc Med 1998;91: 268–9. 8. Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913–26. 9. Bremner WG, Kumar CM. Delayed surgical emphysema, pneumomediastinum and bilateral pneumothoraces after postoperative vomiting. Br J Anaesth 1993;71:296–7.
British Journal of Oral and Maxillofacial Surgery 46 (2008) 136–137
Short communication
Pneumomediastinum, bilateral pneumothorax, pleural effusion, and surgical emphysema after routine apicectomy caused by vomiting Archita Gulati a,∗ , Andrew Baldwin b , Ian Mc. Intosh c , A. Krishnan d a
General Surgery at Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom Department of Oral Surgery, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom c Department of Surgery, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom d Department of Anaesthesia, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, United Kingdom b
Accepted 20 November 2006 Available online 25 January 2007
Abstract Mediastinal and subcutaneous emphysema may occur after dental and oral surgery as a result of iatrogenic introduction of air or injury to the tracheobronchial tree. We report a patient who developed emphysema and pneumothorax after dentoalveolar surgery, which made diagnosis and management difficult. We suggest that persistent postoperative vomiting caused inhalation of mediastinal and intrathoracic air. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Pneumomediastinum; Emphysema; Vomiting; Dental surgery
Case report A 43-year-old woman had apicectomy of four maxillary teeth under general anaesthesia. She was a smoker and had chronic obstructive airways disease. She had routine fibre optic intubation. As she was slightly drowsy in the recovery room, she was admitted overnight for observation. Three hours after intubation she developed intractable vomiting followed by chest pain, diplopia, and facial and neck swelling. She had a tachycardia (105 beats/min) and respiratory distress, with subcutaneous emphysema over the face, neck, and chest wall. Chest radiograph showed mediastinal air and massive surgical emphysema (Fig. 1). A contrast-enhanced computed tomogram (CT) of the chest and abdomen confirmed mediastinal emphysema and an extensive pneumothorax (Fig. 2). Though there was no ∗ Corresponding author at: Department of Surgery, Christie Hospitals NHS Trust, Wilmslow Road M204 BX, United Kingdom. Tel.: +44 1614468051; fax: +44 1616278774. E-mail address: [email protected] (A. Gulati).
extravasation of contrast, pneumoperitoneum was reported. Because we suspected rupture of the lower end of the oesophagus caused by severe vomiting, she had an exploratory laparotomy after bilateral chest drains had been inserted but this showed nothing untoward. Operative gastroscopy was also within normal limits and showed no oesophageal rupture. She made a slow postoperative recovery and required artificial ventilation for several days. She was discharged a month after her original procedure.
Discussion Air may present suddenly in the neck, subcutaneous tissues, mediastinum, and retroperitoneal soft tissues with no apparent explanation. This warrants urgent investigation. Several mechanisms have been implicated including suppurative infections such as dental abscess or mediastinitis, direct introduction of air after mucosal or cutaneous disruption such as dental procedures; Boerhaave’s syn-
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.11.008
A. Gulati et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 136–137
Fig. 1. Massive bilateral subcutaneous emphysema and mediastinal air (arrow).
137
The mucosa may also be disrupted after a difficult intubation, with injury to the tracheobronchial passages, leading to the rapid onset of emphysema and pneumothorax. However, our patient had no symptoms for several hours after extubation. Mediastinal and intraperitoneal air, as suspected in our patient, can occur in Boerhaave’s syndrome, which is spontaneous rupture of the distal oesophagus as a result of intractable vomiting that causes a sudden rise in intraluminal oesophageal pressure; this prevents the cricopharyngeus muscle from relaxing .5 It presents with chest pain, mediastinitis, effusion, and pneumothorax, and warrants emergency intervention.6 The presence of air at the bases of a hyperinflated lung in a chronically obstructed airway was misinterpreted as pneumoperitoneum on CT, which unfortunately led to an unnecessary operation. Spontaneous pneumothorax also results from barotrauma and has been described during labour,7 sneezing, coughing, and straining at stool, or Valsalva manouvre.1 The most common cause of mediastinal emphysema is alveolar rupture, which has been described by Macklin.8 We think that barotrauma after vomiting was the cause of the pneumomediastinum and subcutaneous emphysema in our patient. We know of only one previous report of vomiting as a cause of pneumothorax and pneumomediastinum.9 References
Fig. 2. Computed tomogram of upper thorax showing surgical emphysema of the soft tissue spaces of the neck, and bilateral pneumothoraces at the apexes of the lungs.
drome or traumatic intubation; or spontaneously after barotrauma.1 Pneumomediastinum and pneumothorax may occur after dental extraction, root canal treatment, or drilling of third molars2 when a high speed air turbine drill is used, or an air-water cooled syringe,3 because the soft tissue spaces of the neck communicate with the mediastinum.4 Air can track from the sublingual and submandibular spaces to the pterygomandibular, parapharyngeal, and retropharyngeal spaces, and then to the mediastinum and pleural spaces. However, the drill used in our case was a surgical air drill (closed system), unlike the air turbine used in dental surgeries for restorative dentistry. This drill had a lower free speed of 0–50,000 revolutions/second. No faults were detected when the equipment was examined postoperatively.
1. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Arch Intern Med 1984;144:1447–53. 2. Sandler CM, Libshitz H, Marks G. Pneumoperitoneum, pneumomediastinum, pneumopericardium following dental extraction. Radiology 1975;115:539–40. 3. Barkdull TJ. Pneumothorax during dental care. J Am Board Fam Pract 2003;16:165–9. 4. Salib RJ, Valentine P, Akhtar S. Surgical emphysema following dental treatment. J Laryngol Otol 1999;13:756–8. 5. Pate JW, Walker WA, Cole FH, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689–92. 6. Bjerke HS. Boerhaave’s syndrome and barogenic injuries of the esophagus. Chest Surg Clin N Am 1994;4:819–25. 7. Turner M, Benton PJ. Three cases of pneumomediastinum - after labour, sneezing and compressed-air diving. J R Soc Med 1998;91: 268–9. 8. Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913–26. 9. Bremner WG, Kumar CM. Delayed surgical emphysema, pneumomediastinum and bilateral pneumothoraces after postoperative vomiting. Br J Anaesth 1993;71:296–7.