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Tissue Space Emphysema from an Air Turbine Handpiece
T issu e sp a c e em p h y sem a from a n air tu rb in e h an d p iece W. W. McGrannahan, DDS, Kansas City, Mo Emphysema is a hazard when the air tur bine handpiece is used during oral sur gery. During sectioning of an impacted lower third molar, the patient described in this report developed slight pneumo mediastinum. An air turbine handpiece emitting an air-water spray was used in the sectioning procedure.
L IT E R A T U R E
The report of Turnbull,2 a classic in the history of dental surgical emphysema, de scribes a navy bugler who pumped air into his facial tissues after the extraction of a bicuspid. Stockdale,3 Edwards,1 Brown4 and several others have reported this phenomenon after oral surgery and associated it with nose blowing, coughing and spitting. One of the most comprehen As compressed air becomes more com sive studies of case reports was done re mon as the power source for dental in cently by Oswalt.5 struments, there seems to be an increase in the reports of surgical emphysema. Edwards1 defines surgical emphysema as “a condition wherein air has pene A lower left second molar and a tissuetrated the connective tissues of a region impacted lower left third molar were re and remains there subcutaneously. It fol moved from a 39-year-old Caucasian lows trauma or a surgical operation when man. The second molar, which was air is introduced forcibly through a break abscessed, was removed without incident. in the tissues.” Surgical (or traumatic) The third molar required sectioning. The emphysema can be classified under two air turbine handpiece used in this proce headings: (1) subcutaneous emphysema dure emitted an atomized spray of air •—gaseous invasion of the connective tis and water. During sectioning, there was sues immediately beneath the dermal a sudden swelling of the left side of the layers and (2) tissue space emphysema— face from the region of the eye to the the passage and collection of gas between left cervical region. Surgery was com the tissue space or fascial planes. Tissue pleted without further complication. The space emphysema seems to occur more cause and probable course of emphysema frequently . than subcutaneous emphy were explained to the patient, who ex pressed a desire to see his physician. Med sema. REPO RT O F CASE
M c G ranna han: EM PH YSEM A CAUSED BY A IR TURBINE -885
ical consultation was encouraged; how ever, the patient waited until the next day to be examined. During the night, the air diffused across the neck into the opposite cervical region. The patient suffered some sore ness throughout the left side of the face and neck and a mild choking sensation with attendant shortness of breath after exertion. There seemed to be little, if any, obstruction of breathing. The patient also reported chills and fever at night. The next day, his voice was higher than usual and “brassy,” which is typical of lesions of the superior mediastinum. Body temperature was normal. Palpation disclosed crepitus of the tissues through out the entire cervical region and extend ing back to the trapezius muscles. The suprasternal notch was obliterated. There was no displacement of the trachea, and auscultation of the heart and lungs did not reveal any abnormality. The radiologist reported extensive sub cutaneous emphysema of the neck, ex tending from the clavicles to the mandi ble (illustration). The lungs were normal, and there was no evidence of pneumo thorax. A diagnosis of slight pneumo mediastinum was made. TREATM ENT AND
COURSE
OF
D IS E A S E
The introduction of contaminated debris into the tissue spaces seemed highly prob able; thus, the patient was placed on pen icillin therapy. He was advised to rest at home and check his temperature peri odically. During the next four days, air in the tissue spaces gradually dissipated. Re sidual soreness of the structures of the neck lasted about ten days. There was no elevation of body temperature. Recovery is considered complete. C O N C L U S IO N S
It seems obvious that the cause of this accident was the forced air and water
A n t e r o p o s t e r io r r a d io g r a p h ( s o f t tis s u e t e c h n i c ) s how s m u lt ip l e s tr e a k s a n d p o c k e ts o f a ir w it h in s o f t tis s u e , e x t e n d in g f r o m c la v ic le s s u p e r io r ly o v e r m a n d ib le
from the air turbine handpiece. It might be that, had the air-water spray not been used, the inflation of the tissue would not have occurred. This type instrument, however, has an exhaust vent which emits forced air whether or not the spray is being used. It is conceivable that, if the head of the instrument were inadvert ently covered by a flap of soft tissue, the exhaust might introduce air into the tis sues. It is the author’s opinion that an air turbine handpiece should not be used for the sectioning technic in oral surgery. 200 Plaza Time Building
1. Edwards, R. W . S u rg ic a l em physem a a ft e r to o th re m o v a l. J . O ra l S urg. 6:147 A p ril 1948; J . Kansas D .A . 32:11 O c t. 1948; J . M issouri D .A . 28:283 A u g . 1948. 2. Turn b u ll, A . A re m a rk a b le c o in c id en c e in d e n ta l surgery. Brit. M .J . 1:1131 M a y 1900. 3. S to c k d a le , C . R. S u rg ic a l em physem a o f the fac e fo llo w in g a m id d le th ird fra c tu re . O ra l S urg ., O ra l M e d . & O ra l Path. 11:135 Fe b . 1958. 4. Brown, C . J ., J r. Subcutaneous em physem a o f the fa c e . J . Kansas D .A . 34:94 S e p t. 1950. 5. O s w a lt, T. © . Em physem a: case histories and c o n clusion?. J . Mississippi D .A . 19:12 J a n . 1963.
L IT E R A T U R E
The report of Turnbull,2 a classic in the history of dental surgical emphysema, de scribes a navy bugler who pumped air into his facial tissues after the extraction of a bicuspid. Stockdale,3 Edwards,1 Brown4 and several others have reported this phenomenon after oral surgery and associated it with nose blowing, coughing and spitting. One of the most comprehen As compressed air becomes more com sive studies of case reports was done re mon as the power source for dental in cently by Oswalt.5 struments, there seems to be an increase in the reports of surgical emphysema. Edwards1 defines surgical emphysema as “a condition wherein air has pene A lower left second molar and a tissuetrated the connective tissues of a region impacted lower left third molar were re and remains there subcutaneously. It fol moved from a 39-year-old Caucasian lows trauma or a surgical operation when man. The second molar, which was air is introduced forcibly through a break abscessed, was removed without incident. in the tissues.” Surgical (or traumatic) The third molar required sectioning. The emphysema can be classified under two air turbine handpiece used in this proce headings: (1) subcutaneous emphysema dure emitted an atomized spray of air •—gaseous invasion of the connective tis and water. During sectioning, there was sues immediately beneath the dermal a sudden swelling of the left side of the layers and (2) tissue space emphysema— face from the region of the eye to the the passage and collection of gas between left cervical region. Surgery was com the tissue space or fascial planes. Tissue pleted without further complication. The space emphysema seems to occur more cause and probable course of emphysema frequently . than subcutaneous emphy were explained to the patient, who ex pressed a desire to see his physician. Med sema. REPO RT O F CASE
M c G ranna han: EM PH YSEM A CAUSED BY A IR TURBINE -885
ical consultation was encouraged; how ever, the patient waited until the next day to be examined. During the night, the air diffused across the neck into the opposite cervical region. The patient suffered some sore ness throughout the left side of the face and neck and a mild choking sensation with attendant shortness of breath after exertion. There seemed to be little, if any, obstruction of breathing. The patient also reported chills and fever at night. The next day, his voice was higher than usual and “brassy,” which is typical of lesions of the superior mediastinum. Body temperature was normal. Palpation disclosed crepitus of the tissues through out the entire cervical region and extend ing back to the trapezius muscles. The suprasternal notch was obliterated. There was no displacement of the trachea, and auscultation of the heart and lungs did not reveal any abnormality. The radiologist reported extensive sub cutaneous emphysema of the neck, ex tending from the clavicles to the mandi ble (illustration). The lungs were normal, and there was no evidence of pneumo thorax. A diagnosis of slight pneumo mediastinum was made. TREATM ENT AND
COURSE
OF
D IS E A S E
The introduction of contaminated debris into the tissue spaces seemed highly prob able; thus, the patient was placed on pen icillin therapy. He was advised to rest at home and check his temperature peri odically. During the next four days, air in the tissue spaces gradually dissipated. Re sidual soreness of the structures of the neck lasted about ten days. There was no elevation of body temperature. Recovery is considered complete. C O N C L U S IO N S
It seems obvious that the cause of this accident was the forced air and water
A n t e r o p o s t e r io r r a d io g r a p h ( s o f t tis s u e t e c h n i c ) s how s m u lt ip l e s tr e a k s a n d p o c k e ts o f a ir w it h in s o f t tis s u e , e x t e n d in g f r o m c la v ic le s s u p e r io r ly o v e r m a n d ib le
from the air turbine handpiece. It might be that, had the air-water spray not been used, the inflation of the tissue would not have occurred. This type instrument, however, has an exhaust vent which emits forced air whether or not the spray is being used. It is conceivable that, if the head of the instrument were inadvert ently covered by a flap of soft tissue, the exhaust might introduce air into the tis sues. It is the author’s opinion that an air turbine handpiece should not be used for the sectioning technic in oral surgery. 200 Plaza Time Building
1. Edwards, R. W . S u rg ic a l em physem a a ft e r to o th re m o v a l. J . O ra l S urg. 6:147 A p ril 1948; J . Kansas D .A . 32:11 O c t. 1948; J . M issouri D .A . 28:283 A u g . 1948. 2. Turn b u ll, A . A re m a rk a b le c o in c id en c e in d e n ta l surgery. Brit. M .J . 1:1131 M a y 1900. 3. S to c k d a le , C . R. S u rg ic a l em physem a o f the fac e fo llo w in g a m id d le th ird fra c tu re . O ra l S urg ., O ra l M e d . & O ra l Path. 11:135 Fe b . 1958. 4. Brown, C . J ., J r. Subcutaneous em physem a o f the fa c e . J . Kansas D .A . 34:94 S e p t. 1950. 5. O s w a lt, T. © . Em physem a: case histories and c o n clusion?. J . Mississippi D .A . 19:12 J a n . 1963.