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Subcutaneous emphysema and pneumomediastinum after tonsillectomy
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212 – 215 www.elsevier.com/locate/amjoto
Subcutaneous emphysema and pneumomediastinum after tonsillectomy☆ Jin Pyeong Kim, MDa , Jung Je Park, MD, PhDa,⁎, Hung Soo Kang, MDa , Min Sung Song, MDb a
Department of Otolaryngology, Institute of Health Sciences, College of Medicine, Gyeongsang National University, Jinju, South Korea b Department of Otolaryngology, Yeil Medical Center, Yeil Otolaryngology Clinics, Masan, South Korea Received 6 February 2009
Abstract
Many patients and their families regard tonsillectomy as a minor operation because it is performed so commonly. However, although tonsillectomy is indeed a relatively safe surgical procedure, in extremely rare cases, it can be complicated by subcutaneous emphysema and pneumomediastinum. Although these complications resolve spontaneously in most cases, a few conclude in tension pneumothorax and other fatal complications. The mechanism by which subcutaneous emphysema and pneumomediastinum develop after tonsillectomy is poorly understood. We experienced a case in which subcutaneous emphysema, pneumomediastinum, and a deep defect in the tonsillar fossa were observed. The passage of air was shown by radiology and histopathology. Consequently, the case is reported here. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Tonsillectomy is a frequently performed surgical procedure in the field of otolaryngology and is used to treat chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscess and various other conditions. Although tonsillectomy is a relatively safe surgical procedure, it is nevertheless associated with several complications, including bleeding, infection, lingual edema, injury of the glossopharyngeal nerve, and injury of the carotid artery [1]. In addition, the complications of subcutaneous emphysema and pneumomediastinum can also occur, albeit much more rarely. The latter complications were reported for the first time in 1953 and have since that time been reported only very infrequently [2]. Although the complications of cervical subcutaneous emphysema with pneumomediastinum after tonsillectomy reflect the inadvertent introduction of air, the passage of air to the mediastinum and subcutaneous tissues ☆
Conflict of interest notification: any actual or potential conflicts of interest do not exist. ⁎ Corresponding author. Department of Otolaryngology, College of Medicine, Gyeongsang National University, Jinju, 660-702, South Korea. Tel.: +82 55 750 8698; fax: +82 55 759 0613. E-mail addresses: [email protected], [email protected] (J.J. Park). 0196-0709/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2009.02.004
has rarely been observed directly. We experienced a case in which the passage of air was radiologically and histopathologically apparent. We report this case and also provide a literature review.
2. Case A 36-year-old healthy woman who suffered frequently from tonsillitis was admitted for tonsillectomy. The preoperative physical examination revealed no other abnormalities. Tonsillectomy was performed under general anesthesia with orotracheal intubation. The tonsils were removed by monopolar electrodissection, and hemostasis was achieved by bipolar cautery. There was little bleeding, but the dissection was difficult because of the adhesion of the tonsils to the tonsillar bed. On the first postoperative day, the patient complained of pain in the submandibular area. A physical examination revealed right facial and neck swelling and crepitus. Inspection of the tonsillar fossa revealed a deep defect, but a mucosal tear was not observed (Fig. 1). The patient had no signs of airway, ventilator, or hemodynamic embarrassment. Apart for several coughs in the postoperative period, there were no special events.
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215
Fig. 1. View of the right tonsillar fossa after tonsillectomy. The arrow indicates a defect in the right tonsillar bed.
A chest x-ray revealed subcutaneous emphysema and pneumomediastinum and a computed tomographic scan also showed subcutaneous emphysema of the face and neck along with a large volume of air and a muscle defect in the right tosillar fossa. The emphysema extended superiorly to the soft palate and tracked inferiorly into the upper mediastinum along the parapharyngeal and retropharyngeal spaces (Fig. 2). Based on these observations, the patient was diagnosed with cervical subcutaneous emphysema and pneumomediastinum that developed after tonsillectomy. A combination of broad-spectrum antibiotics was injected intravenously, and the patient was restricted to bed-rest and instructed to refrain from coughing and vomiting. Two days after surgery, the patient showed mild fever, and plain radiographs revealed pneumonia and pleural effusion. Four days after surgery, the fever was no longer detected, and chest plain radiography revealed a substantial decrease in the pneumonia and pleural effusion. In addition, the subcutaneous emphysema in the neck area was found to have decreased substantially. Histopathological examination of the 2 resected specimens revealed the presence in the right tonsil specimen of muscles along with the tonsil. The patient was discharged with a good prognosis a week after surgery. Up until now, follow-up visits have found her to be in good health without any special findings.
213
techniques, they can also arise from injury during intubation, excessive positive ventilation, and excessive manual ventilation [3,4]. After the mucosal damage, the air flows in through the superior constrictor muscle and descends to the cervicoparapharyngeal space by following the cervicofascial plane. Because the paraphayrngeal and retropharyngeal spaces are connected anatomically, the air then travels to the mediastinum. In some rare cases, the air that has descended to the mediastinum may then descend further to the abdominal cavity via the diaphragmatic aperture [5,6]. Subcutaneous emphysema is typically associated with crepitus, and the subcutaneous air can be detected relatively readily by radiological imaging. If the patient showing subcutaneous emphysema also has dyspnea, dysphagia, chest and back pain, cyanosis, and Hamman's sign (crepitus synchronous with systole), pneumomediastinum should be suspected [7]. We performed a MEDLINE review of the Englishlanguage literature of all reported cases of subcutaneous emphysema with pneumomediastinum following tonsillectomy. We identified 10 such cases. The details of these 10 cases together with the details of our case reported here are presented in Table 1. Of the 11 patients, 3 were men and 8 were women. The mean age was 20.8 years (age range, 436 years). Tonsillectomy was performed in 3 (27.3%) and 4 (36.4%) cases by electrodissection and the snare technique, respectively. The surgical technique used in the remaining 4 cases was not indicated. The reasons for tonsillectomy included frequent bouts of tonsillitis or the previous development of a peritonsillar abscess. It is possible that
3. Discussion Subcutaneous emphysema can be a complication of a variety of oral and maxillofacial surgical procedures where mucosal integrity is breached. It has been reported that the development of subcutaneous emphysema in the oral cavity after surgery is caused by injury to the pharyngolaryngeal mucosa [3]. Although such injuries can be caused by surgical
Fig. 2. Axial computed tomography reveals subcutaneous emphysema and pneumomediastinum. The arrows indicate the air in the neck and chest.
214
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215
Table 1 Reported cases of subcutaneous emphysema and pneumomediastinum after tonsillectomy Authors
Year
Sex/Age (years)
Symptoms
Treatments
Technique
Resolving time
Knutson and Ouellette [2] Ferguson et al [5]
1954
M/6
?
Antibiotics
Snare technique
7d
1955
F/4
Thoracotomy, transfusion
Snare technique
10 d
Pratt et al [8] Prupas and Fordham [9] Braverman et al [10]
1958 1976
F/9 M/22
Dyspnea, abdominal dytension, heart was shifted ? Dyspnea, anterior chest pain
Thoracotomy Observation
? ?
6d ?
1997
F/22
Observation
Snare technique
7d
Marioni et al [4] Yammine et al [11]
2003 2004
F/34 M/36
Antibiotics Antibiotics
? Snare technique
? 7d
Stewart et al [12] Shine et al [13]
2004 2005
F/22 F/7
Antibiotics Oxygen, antibiotics, ICU care
Electrodissection Electrodissection
3 wk 6d
Panerari et al [14]
2005
F/31
?
5d
Present study
2008
F/36
Suture and close muscular planes, tracheostomy, antibiotics Antibiotics
Electrodissection
7d
Sore throat Chest pain Dyspnea ? Pain and swelling at the op site, difficulty swallowing ? Neck pain, limited neck movement Stridor Dyspnea Neck swelling
Question mark indicates unknown; M, male; F, female; ICU, intensive care unit.
the subcutaneous emphysema and pneumomediastinum in these 11 cases are the result of severe adhesion to the superior constrictor muscle, which made it difficult to dissect the tonsils from the tonsil capsule and led to substantial injury to the tonsillar fossa during surgery. Two cases required a tracheotomy, and 1 case involved a thoracotomy. Thus, in total, 3 cases (27.2%) required aggressive treatment of the subcutaneous emphysema and pneumomediastinum. Although none of the 11 patients died, subcutaneous emphysema and pneumomediastinum can be fatal complications, which means that patients undergoing tonsillectomy should be monitored closely, and follow-up observation is required. Treatment of patients with subcutaneous emphysema and pneumomediastinum involves regular assessment of the airway and the extent of the emphysema. Any activity that increases upper airway pressure such as coughing, vomiting, and straining or vigorous activity should be avoided. Therefore, it may be appropriate to recommend bed rest and restriction of oral intake, the administration of a cough suppressant and a stool softener, and sedation. Broadspectrum antibiotics may also be prescribed. In addition, to prevent the secondary entrance of bacteria to the subcutaneous emphysema and extension of surgical emphysema, the injured mucosa may be sutured [11,14]. In the case described here, while a deep defect in the tonsillar bed was detected on the first postoperative day, the subcutaneous emphysema did not progress any further, and Hamman's sign was not observed. Consequently, the injured mucosa was not sutured. All 11 patients improved on average in 8.6 days (range, 5 days to 3 weeks). In most cases, the subcutaneous emphysema and pneumomediasti-
num resolved spontaneously and, as mentioned, none of the patients were reported to have died. Most authors suggest that air enters the cervical fascial plane via injury to the superior constrictor muscle during the removal of the palatine tonsils [12]. Indeed, in our case, we had difficulty dissecting the tonsil from the tonsillar bed because of severe adhesion of the tonsil to the bed, and after the operation, a deep defect was detected in the right tonsillar fossa. In addition, histological analysis of the resected specimen revealed the presence of muscle along with the tonsil, which confirms that the tonsillar fossa and muscles were resected together by blunt deep dissection. Because radiographic tests after the operation revealed abundant air in the vicinity of the tonsillar fossa defect, this strongly supports the notion that the defect may have been the cause of the subcutaneous emphysema and pneumomediastinum. These observations suggest in turn that, for cases showing severe adhesion of the tonsil to the tonsillar bed, high-voltage electrodissection and the blunt snare technique should be avoided, and instead, more meticulous bipolar dissection that delivers less thermal damage should be performed. This would most likely prevent the development of severe postsurgical complications such as subcutaneous emphysema and pneumosmediastinum. References [1] Mistry D, Kelly G. Consent for tonsillectomy. Clin Otolaryngol Allied Sci 2004;29:362-8. [2] Knutson RC, Ouellette AJ. Subcutaneous emphysema following tonsillectomy and adenoidectomy. Minn Med 1954;37:877-9.
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215 [3] Miman MC, Ozturan O, Dormus M, et al. Cervical subcutaneous emphysema: an unusual complication of adenotonsillectomy. Paediatr Anaesth 2001;11:491-3. [4] Marioni G, Filippis C, Tregnaghi A, et al. Cervical emphysema and pneumomediastinum after tonsillectomy: It can happen. Otolaryngol Head Neck Surg 2003;128:298-300. [5] Ferguson CC, Mcgarry PM, Beckman IH, et al. Surgical emphysema complicating tonsillectomy and dental extraction. Can Med Assoc J 1955;72:847-8. [6] Vos GD, Marres EH, Heineman E, et al. Tension pneumoperitoneum as an early complication after adenotonsillectomy. J Laryngol Otol 1995; 109:440-1. [7] Nishino H, Kenmochi M, Kasugai S, et al. Subcutaneous emphysema secondary to tonsillectomy: a case report. Auris, Nasus, Larynx 2003; 30:135-6. [8] Pratt LW, Hornberger HR, Moore VJ. Mediastinal emphysema complicating tonsillectomy and adenoidectomy. Ann Otol Rhinol Laryngol 1962;71:158-69.
215
[9] Prupas HM, Fordham SD. Emphysema secondary to tonsillectomy. Laryngoscope 1977;87:1134-6. [10] Braverman I, Rosenmann E, Elidan E. Closed rhinolalia as a symptom of pneumomediastinum after tonsillectomy: a case report and literature review. Otolaryngol Head Neck Surg 1997;116:551-3. [11] Yammine NV, Alherabi A, Gerin-Lajoie J. Post-tonsillectomy subcutaneous emphysema and pneumomediastinum. J Otolaryngol 2004;33: 403-4. [12] Stewart AE, Brewster DF, Bernstein PE. Subcutaneous emphysema and pneumomediastinum complicating tonsillectomy. Arch Otolaryngol Head Neck Surg 2004;130:1324-7. [13] Shine NP, Sader C, Coates H. Cervicofacial emphysema and pneumomediastinum following pediatric adenotonsillectomy: a rare complication. Int J Pediatr Otorhinolaryngol 2005;69: 1579-82. [14] Panerari AC, Soter AC, Silva FL, et al. Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report. Braz J Otorhinolaryngol 2005;71:94-6.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212 – 215 www.elsevier.com/locate/amjoto
Subcutaneous emphysema and pneumomediastinum after tonsillectomy☆ Jin Pyeong Kim, MDa , Jung Je Park, MD, PhDa,⁎, Hung Soo Kang, MDa , Min Sung Song, MDb a
Department of Otolaryngology, Institute of Health Sciences, College of Medicine, Gyeongsang National University, Jinju, South Korea b Department of Otolaryngology, Yeil Medical Center, Yeil Otolaryngology Clinics, Masan, South Korea Received 6 February 2009
Abstract
Many patients and their families regard tonsillectomy as a minor operation because it is performed so commonly. However, although tonsillectomy is indeed a relatively safe surgical procedure, in extremely rare cases, it can be complicated by subcutaneous emphysema and pneumomediastinum. Although these complications resolve spontaneously in most cases, a few conclude in tension pneumothorax and other fatal complications. The mechanism by which subcutaneous emphysema and pneumomediastinum develop after tonsillectomy is poorly understood. We experienced a case in which subcutaneous emphysema, pneumomediastinum, and a deep defect in the tonsillar fossa were observed. The passage of air was shown by radiology and histopathology. Consequently, the case is reported here. © 2010 Elsevier Inc. All rights reserved.
1. Introduction Tonsillectomy is a frequently performed surgical procedure in the field of otolaryngology and is used to treat chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscess and various other conditions. Although tonsillectomy is a relatively safe surgical procedure, it is nevertheless associated with several complications, including bleeding, infection, lingual edema, injury of the glossopharyngeal nerve, and injury of the carotid artery [1]. In addition, the complications of subcutaneous emphysema and pneumomediastinum can also occur, albeit much more rarely. The latter complications were reported for the first time in 1953 and have since that time been reported only very infrequently [2]. Although the complications of cervical subcutaneous emphysema with pneumomediastinum after tonsillectomy reflect the inadvertent introduction of air, the passage of air to the mediastinum and subcutaneous tissues ☆
Conflict of interest notification: any actual or potential conflicts of interest do not exist. ⁎ Corresponding author. Department of Otolaryngology, College of Medicine, Gyeongsang National University, Jinju, 660-702, South Korea. Tel.: +82 55 750 8698; fax: +82 55 759 0613. E-mail addresses: [email protected], [email protected] (J.J. Park). 0196-0709/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2009.02.004
has rarely been observed directly. We experienced a case in which the passage of air was radiologically and histopathologically apparent. We report this case and also provide a literature review.
2. Case A 36-year-old healthy woman who suffered frequently from tonsillitis was admitted for tonsillectomy. The preoperative physical examination revealed no other abnormalities. Tonsillectomy was performed under general anesthesia with orotracheal intubation. The tonsils were removed by monopolar electrodissection, and hemostasis was achieved by bipolar cautery. There was little bleeding, but the dissection was difficult because of the adhesion of the tonsils to the tonsillar bed. On the first postoperative day, the patient complained of pain in the submandibular area. A physical examination revealed right facial and neck swelling and crepitus. Inspection of the tonsillar fossa revealed a deep defect, but a mucosal tear was not observed (Fig. 1). The patient had no signs of airway, ventilator, or hemodynamic embarrassment. Apart for several coughs in the postoperative period, there were no special events.
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215
Fig. 1. View of the right tonsillar fossa after tonsillectomy. The arrow indicates a defect in the right tonsillar bed.
A chest x-ray revealed subcutaneous emphysema and pneumomediastinum and a computed tomographic scan also showed subcutaneous emphysema of the face and neck along with a large volume of air and a muscle defect in the right tosillar fossa. The emphysema extended superiorly to the soft palate and tracked inferiorly into the upper mediastinum along the parapharyngeal and retropharyngeal spaces (Fig. 2). Based on these observations, the patient was diagnosed with cervical subcutaneous emphysema and pneumomediastinum that developed after tonsillectomy. A combination of broad-spectrum antibiotics was injected intravenously, and the patient was restricted to bed-rest and instructed to refrain from coughing and vomiting. Two days after surgery, the patient showed mild fever, and plain radiographs revealed pneumonia and pleural effusion. Four days after surgery, the fever was no longer detected, and chest plain radiography revealed a substantial decrease in the pneumonia and pleural effusion. In addition, the subcutaneous emphysema in the neck area was found to have decreased substantially. Histopathological examination of the 2 resected specimens revealed the presence in the right tonsil specimen of muscles along with the tonsil. The patient was discharged with a good prognosis a week after surgery. Up until now, follow-up visits have found her to be in good health without any special findings.
213
techniques, they can also arise from injury during intubation, excessive positive ventilation, and excessive manual ventilation [3,4]. After the mucosal damage, the air flows in through the superior constrictor muscle and descends to the cervicoparapharyngeal space by following the cervicofascial plane. Because the paraphayrngeal and retropharyngeal spaces are connected anatomically, the air then travels to the mediastinum. In some rare cases, the air that has descended to the mediastinum may then descend further to the abdominal cavity via the diaphragmatic aperture [5,6]. Subcutaneous emphysema is typically associated with crepitus, and the subcutaneous air can be detected relatively readily by radiological imaging. If the patient showing subcutaneous emphysema also has dyspnea, dysphagia, chest and back pain, cyanosis, and Hamman's sign (crepitus synchronous with systole), pneumomediastinum should be suspected [7]. We performed a MEDLINE review of the Englishlanguage literature of all reported cases of subcutaneous emphysema with pneumomediastinum following tonsillectomy. We identified 10 such cases. The details of these 10 cases together with the details of our case reported here are presented in Table 1. Of the 11 patients, 3 were men and 8 were women. The mean age was 20.8 years (age range, 436 years). Tonsillectomy was performed in 3 (27.3%) and 4 (36.4%) cases by electrodissection and the snare technique, respectively. The surgical technique used in the remaining 4 cases was not indicated. The reasons for tonsillectomy included frequent bouts of tonsillitis or the previous development of a peritonsillar abscess. It is possible that
3. Discussion Subcutaneous emphysema can be a complication of a variety of oral and maxillofacial surgical procedures where mucosal integrity is breached. It has been reported that the development of subcutaneous emphysema in the oral cavity after surgery is caused by injury to the pharyngolaryngeal mucosa [3]. Although such injuries can be caused by surgical
Fig. 2. Axial computed tomography reveals subcutaneous emphysema and pneumomediastinum. The arrows indicate the air in the neck and chest.
214
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215
Table 1 Reported cases of subcutaneous emphysema and pneumomediastinum after tonsillectomy Authors
Year
Sex/Age (years)
Symptoms
Treatments
Technique
Resolving time
Knutson and Ouellette [2] Ferguson et al [5]
1954
M/6
?
Antibiotics
Snare technique
7d
1955
F/4
Thoracotomy, transfusion
Snare technique
10 d
Pratt et al [8] Prupas and Fordham [9] Braverman et al [10]
1958 1976
F/9 M/22
Dyspnea, abdominal dytension, heart was shifted ? Dyspnea, anterior chest pain
Thoracotomy Observation
? ?
6d ?
1997
F/22
Observation
Snare technique
7d
Marioni et al [4] Yammine et al [11]
2003 2004
F/34 M/36
Antibiotics Antibiotics
? Snare technique
? 7d
Stewart et al [12] Shine et al [13]
2004 2005
F/22 F/7
Antibiotics Oxygen, antibiotics, ICU care
Electrodissection Electrodissection
3 wk 6d
Panerari et al [14]
2005
F/31
?
5d
Present study
2008
F/36
Suture and close muscular planes, tracheostomy, antibiotics Antibiotics
Electrodissection
7d
Sore throat Chest pain Dyspnea ? Pain and swelling at the op site, difficulty swallowing ? Neck pain, limited neck movement Stridor Dyspnea Neck swelling
Question mark indicates unknown; M, male; F, female; ICU, intensive care unit.
the subcutaneous emphysema and pneumomediastinum in these 11 cases are the result of severe adhesion to the superior constrictor muscle, which made it difficult to dissect the tonsils from the tonsil capsule and led to substantial injury to the tonsillar fossa during surgery. Two cases required a tracheotomy, and 1 case involved a thoracotomy. Thus, in total, 3 cases (27.2%) required aggressive treatment of the subcutaneous emphysema and pneumomediastinum. Although none of the 11 patients died, subcutaneous emphysema and pneumomediastinum can be fatal complications, which means that patients undergoing tonsillectomy should be monitored closely, and follow-up observation is required. Treatment of patients with subcutaneous emphysema and pneumomediastinum involves regular assessment of the airway and the extent of the emphysema. Any activity that increases upper airway pressure such as coughing, vomiting, and straining or vigorous activity should be avoided. Therefore, it may be appropriate to recommend bed rest and restriction of oral intake, the administration of a cough suppressant and a stool softener, and sedation. Broadspectrum antibiotics may also be prescribed. In addition, to prevent the secondary entrance of bacteria to the subcutaneous emphysema and extension of surgical emphysema, the injured mucosa may be sutured [11,14]. In the case described here, while a deep defect in the tonsillar bed was detected on the first postoperative day, the subcutaneous emphysema did not progress any further, and Hamman's sign was not observed. Consequently, the injured mucosa was not sutured. All 11 patients improved on average in 8.6 days (range, 5 days to 3 weeks). In most cases, the subcutaneous emphysema and pneumomediasti-
num resolved spontaneously and, as mentioned, none of the patients were reported to have died. Most authors suggest that air enters the cervical fascial plane via injury to the superior constrictor muscle during the removal of the palatine tonsils [12]. Indeed, in our case, we had difficulty dissecting the tonsil from the tonsillar bed because of severe adhesion of the tonsil to the bed, and after the operation, a deep defect was detected in the right tonsillar fossa. In addition, histological analysis of the resected specimen revealed the presence of muscle along with the tonsil, which confirms that the tonsillar fossa and muscles were resected together by blunt deep dissection. Because radiographic tests after the operation revealed abundant air in the vicinity of the tonsillar fossa defect, this strongly supports the notion that the defect may have been the cause of the subcutaneous emphysema and pneumomediastinum. These observations suggest in turn that, for cases showing severe adhesion of the tonsil to the tonsillar bed, high-voltage electrodissection and the blunt snare technique should be avoided, and instead, more meticulous bipolar dissection that delivers less thermal damage should be performed. This would most likely prevent the development of severe postsurgical complications such as subcutaneous emphysema and pneumosmediastinum. References [1] Mistry D, Kelly G. Consent for tonsillectomy. Clin Otolaryngol Allied Sci 2004;29:362-8. [2] Knutson RC, Ouellette AJ. Subcutaneous emphysema following tonsillectomy and adenoidectomy. Minn Med 1954;37:877-9.
J.P. Kim et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 31 (2010) 212–215 [3] Miman MC, Ozturan O, Dormus M, et al. Cervical subcutaneous emphysema: an unusual complication of adenotonsillectomy. Paediatr Anaesth 2001;11:491-3. [4] Marioni G, Filippis C, Tregnaghi A, et al. Cervical emphysema and pneumomediastinum after tonsillectomy: It can happen. Otolaryngol Head Neck Surg 2003;128:298-300. [5] Ferguson CC, Mcgarry PM, Beckman IH, et al. Surgical emphysema complicating tonsillectomy and dental extraction. Can Med Assoc J 1955;72:847-8. [6] Vos GD, Marres EH, Heineman E, et al. Tension pneumoperitoneum as an early complication after adenotonsillectomy. J Laryngol Otol 1995; 109:440-1. [7] Nishino H, Kenmochi M, Kasugai S, et al. Subcutaneous emphysema secondary to tonsillectomy: a case report. Auris, Nasus, Larynx 2003; 30:135-6. [8] Pratt LW, Hornberger HR, Moore VJ. Mediastinal emphysema complicating tonsillectomy and adenoidectomy. Ann Otol Rhinol Laryngol 1962;71:158-69.
215
[9] Prupas HM, Fordham SD. Emphysema secondary to tonsillectomy. Laryngoscope 1977;87:1134-6. [10] Braverman I, Rosenmann E, Elidan E. Closed rhinolalia as a symptom of pneumomediastinum after tonsillectomy: a case report and literature review. Otolaryngol Head Neck Surg 1997;116:551-3. [11] Yammine NV, Alherabi A, Gerin-Lajoie J. Post-tonsillectomy subcutaneous emphysema and pneumomediastinum. J Otolaryngol 2004;33: 403-4. [12] Stewart AE, Brewster DF, Bernstein PE. Subcutaneous emphysema and pneumomediastinum complicating tonsillectomy. Arch Otolaryngol Head Neck Surg 2004;130:1324-7. [13] Shine NP, Sader C, Coates H. Cervicofacial emphysema and pneumomediastinum following pediatric adenotonsillectomy: a rare complication. Int J Pediatr Otorhinolaryngol 2005;69: 1579-82. [14] Panerari AC, Soter AC, Silva FL, et al. Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report. Braz J Otorhinolaryngol 2005;71:94-6.