Traumatic Subcutaneous Emphysema of the Face Associated With Paranasal Sinus Fractures: A Prospective Study

BASIC AND PATIENT-ORIENTED RESEARCH J Oral Maxillofac Surg 63:1080-1087, 2005

Traumatic Subcutaneous Emphysema of the Face Associated With Paranasal Sinus Fractures: A Prospective Study Bernardo Ferreira Brasileiro, DDS,* André Luís Vieira Cortez, DDS, MS,† Luciana Asprino, DDS, MS,‡ Luis Augusto Passeri, DDS, PhD,§ Márcio de Moraes, DDS, PhD,储 Renato Mazzonetto, DDS, PhD,¶ and Roger William Fernandes Moreira, DDS, PhD** Purpose: The purpose of this report was to review and analyze the epidemiologic features of traumatic

subcutaneous emphysema (TSE) originating from frontal, nasoethmoidal, and maxillary facial injuries with sinusal involvement in the emergency room setting. Patients and Methods: All patients with a fracture involving the paranasal sinuses were evaluated with regard to TSE occurrence. Data analysis extended to gender, age, etiology, fracture sites, TSE location, sinus involvement, treatment, and complications from April 1999 to December 2003. Evaluation methods included computed tomography scan and clinical evaluation. Results: A total of 390 patients sustaining 458 paranasal sinus fractures were included. TSE was observed in 29 patients (7.43%) patients (male-female ratio of 3.83:1, with a mean age of 36.71 ⫾ 15.71 years). The main etiologies were vehicle accidents and assaults. Isolated maxillary sinuses fractures were found in 17 cases (58.62%). Ethmoidal and maxillary fractures were associated with 9 cases (31.03%), and 1 (3.45%) case had maxillary and frontal fractures together. Ethmoidal, maxillary, and frontal fractures were found concomitantly in 2 (6.90%) cases. Periorbital emphysema was the most prevalent site of presentation, and edema (86.21%) and bone deformities (79.31%) were the most frequent findings associated with TSE. Conservative treatment was the prevalent treatment choice (55.17%), and 1 complication because of persistent pain was noted. Conclusion: The results suggest that TSE of the face associated with paranasal sinus fractures maintained the clinical features of its fractures of origin. The ethmoidal sinuses were considered as the most prevalent etiologic site, and the periorbital region was responsible for addressing the higher incidence of SE following paranasal sinus fractures. © 2005 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 63:1080-1087, 2005 Subcutaneous emphysema (SE) of the head and neck is caused by the introduction of air into the fascial planes of the connective tissue. Because of the looseness of this tissue and its distensible walls, air can accumulate in these crevices and convert

them into spaces of considerable size.1 The air may gain access to the fascial planes and produce SE in any situation in which the integrity of the oral mucosa is interrupted and intraoral pressure is increased. This event includes air escape through

Received from the Division of Oral and Maxillofacial Surgery, Campinas State University, Piracicaba Dental School, Piracicaba, São Paulo, Brazil. *Two-year Resident of Oral and Maxillofacial Surgery. †Four-year Resident of Oral and Maxillofacial Surgery. ‡Four-year Resident of Oral and Maxillofacial Surgery. §Associate Professor of Oral and Maxillofacial Surgery. 储Associate Professor of Oral and Maxillofacial Surgery. ¶Associate Professor of Oral and Maxillofacial Surgery.

**Associate Professor of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Moraes: Faculdade de Odontologia de Piracicaba, Centro Cirúrgico Av Limeira, 901, B. Areião, Piracicaba, SP, Brazil 13413-903; e-mail: [email protected] © 2005 American Association of Oral and Maxillofacial Surgeons

0278-2391/05/6308-0004$30.00/0 doi:10.1016/j.joms.2005.04.007

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sinus mucosal laceration in facial fractures affecting the paranasal sinuses.2 SE has been reported in association with lacerations of soft tissue during dental operations,3-8 endodontic treatment,9,10 during scaling and root planning therapy,11 following punch biopsy,12 as a result of facial injuries,2,13-23 and related to ventilation with endotracheal intubation for general anesthesia.5,19,24 Orthognathic surgery performed in the mandible25,26 and maxilla27-29 had also been related to initiate an SE. The pressure that increases air diffusion can be raised by blowing the nose,23 coughing,29,30 sneezing, rinsing the mouth, playing a musical instrument,1 air-generating dental instruments,3-7,11 and air travel.22 Postoperative surgical emphysema may even arise following the use of continuous positive airway pressure31 or a peak flow meter.32 Paranasal sinuses are an important source of initiating air diffusion within facial tissues, which may appear as emphysema secondary to frontal, nasoethmoidal, and maxillary facial trauma.2,15,23 Fractures through a sinus wall with tearing of the lining mucosa allows air to escape into the facial soft tissues, especially those of the periorbital, which are prone to inflation of air owing to their loose areolar nature.33 Most commonly the periorbital SE enters through a defect in the medial orbital wall from the ethmoidal sinuses and, less frequently, from the maxillary sinus or retroseptally.34 The first report in the literature addressing traumatic SE following a facial fracture was described in 1958 by Stockdale.35 The clinical presentation is characterized by sudden onset of facial swelling with sensation of fullness of the face and closing of the eyelids on the affected side. Crepitation, pain, and tenderness may be noted, and subconjunctival ecchymoses may also be present. Crepitation noted upon auscultation with a stethoscope is almost pathognomonic for SE. Otherwise, crepitation is most easily appreciated by alternating rolling of 2 fingers gently over the tissue, which produces a characteristic “crackling” sensation.1,7,20,33 If a large amount of air is introduced into a fascial plane, it may track from the subcutaneous tissues on the face and neck to the mediastinal, pleural space, or retroperitoneal spaces.1,3,19,21,23 The appearance of SE on radiograph is represented as multilocular radiolucency, which may explain the presence of air, usually showing anatomic structure displacement.1,20-22 Its differential diagnosis should include allergic reaction, hematoma, angioedema, esophageal rupture,1 infection, and necrotizing fasciitis.1,20,21 The treatment of SE is mainly supportive, with the air being reabsorbed over a 2- to 14-day period, and requires no treatment other than rational prophylactic coverage with antibiotics because the air intro-

duced into the soft tissues is invariably contaminated. Cough suppressants and decongestants may be prescribed to prevent further air entry. In severe cases, hospitalization may be necessary for observation and closed follow-up radiographs.1,2,20,21,23 Although the sequelae of a SE are generally selflimiting and benign, serious local and systemic complications can result. Dramatic consequences attributed to the accumulated air displacing anatomic structures include loss of vision,2,7,17 cranial nerve weakness,30 pneumothorax, and pneumomediastinum.3,5,6,11,16,18,19,21,23 Infection secondary to contaminated air diffusion is also reported.20 Traumatic SE of the face may occur following a fracture involving the maxillary, ethmoidal, or frontal sinuses. This type of injury also provides a route by which air may be forced into the tissue spaces of the face, especially those of the periorbital region. This study was therefore undertaken to investigate the epidemiology of traumatic SE associated with paranasal sinus fractures in the emergency room setting.

Patients and Methods A prospective, longitudinal study of patients with soft tissue emphysema following facial fractures involving the paranasal sinuses was performed. Patients who reported to the Division of Oral and Maxillofacial Surgery, Campinas State University–Piracicaba Dental School (São Paulo, Brazil), in whom facial fractures involving the paranasal sinuses were diagnosed between April 1, 1999, and December 31, 2003, were enrolled in the study. Patients were evaluated at the hospitals of Santa Casa of Limeira, Santa Casa of Rio Claro, State Hospital of Sumaré and Fornecedores de Cana of Piracicaba, and at Piracicaba Dental School, where ambulatorial returns took place when necessary. The study involved zygomaticomaxillary complex, maxillary, frontal, and nasal-orbital-ethmoidal fractures, associated or not, in which the potential for a midfacial SE development was presented. Radiographic identification of midfacial fractures was performed by occipitomental and posteroanterior plain radiographs and computed tomography (CT). The information retrieval was from a prospective analysis of clinical files designed for oral and maxillofacial trauma, at which data collection included gender, age, fracture location, and clinical presence of facial SE for all patients. Specific records were obtained from patients presenting SE, thus adding information about trauma etiology, emphysema location, paranasal sinus involvement, accompanying signs and symptoms, complications, and treatment of the facial fracture(s). Patients’ inclusion in the group of individuals with soft tissue emphysema following facial fractures of

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Table 1. DESCRIPTION OF 29 CASES OF TRAUMATIC SUBCUTANEOUS EMPHYSEMA FOLLOWING MIDFACIAL FRACTURES

Patient Age (yrs)/ Trauma No. Gender Etiology

Sinus Involvement

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

73/F 31/F 45/M 50/M 17/M 55/M 36/M 36/F 22/M 49/M 38/M 21/M 72/F 29/M 19/M 37/M 54/M 22/M 50/M 18/M 36/F 42/M 26/M

Fall Car accident Assault Assault Assault Assault Assault Fall Car accident Assault Assault Car accident Fall Work accident Motorcycle accident Bicycle accident Bicycle accident Bicycle accident Assault Car accident Car accident Car accident Assault

Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx Mx

24 25 26

26/M 20/M 23/M

Car accident Assault Assault

Mx Mx Mx

27 28 29

53/M 28/M 41/F

Assault Bicycle accident Car accident

Mx Mx Mx

Emphysema Region

Periorbital (R) Periorbital (R) Periorbital (R) ⫹ Eth Periorbital (R/L) Periorbital (L) Periorbital (L) ⫹ Eth Periorbital (R) Periorbital (L) Periorbital (L) Periorbital (L) Periorbital (L) ⫹ Fr Periorbital (R) Periorbital (R) Periorbital (L) ⫹ Eth ⫹ Fr Periorbital (R/L) ⫹ Eth Periorbital (L) Periorbital (L) Periorbital (L) Periorbital (R) Periorbital (L) ⫹ Eth Periorbital (R/L) Periorbital (R/L) ⫹ Eth Periorbital (R) Periorbital, canine, ⫹ Eth masseteric (R/L) Periorbital (R) Periorbital (L) Orbital, infratemporal, masseteric, pterygoid, cervical ⫹ Eth ⫹ Fr (L) ⫹ Eth Periorbital (R/L) ⫹ Eth Periorbital (R)

⫹ Eth

Laceration Complication Treatment No Yes No Yes No No No No Yes No No Yes No Yes Yes Yes No No No No No No No

– – – – – – – – – – – – – – – – – – – – – – –

Conservative Open surgery Conservative Open surgery Conservative Open surgery Open surgery Conservative Open surgery Open surgery Conservative Conservative Conservative Open surgery Open surgery Open surgery Conservative Conservative Conservative Conservative Open surgery Open surgery Conservative

Yes No No

– – –

Open surgery Conservative Conservative

No No No

Pain – –

Open surgery Conservative Conservative

Abbreviations: Mx, maxillary; Eth, ethmoidal; Fr, frontal. Brasileiro et al. TSE of Face from Paranasal Sinus Fractures. J Oral Maxillofac Surg 2005.

the paranasal sinuses was only based on clinical signs of traumatic subcutaneous emphysema (TSE) at the moment of the first appearance in the emergency setting. Those included swelling and crepitation during palpation associated with facial injuries, whereas the exact region and extent of the TSE were also established in accordance with CT scan findings. There were no exclusion criteria.

Results CLINICAL VALUES

Among 1,828 patients suffering from traumatic injuries of the face, 390 patients (334 males, 56 females; mean age, 34.55 ⫾ 15.66 years) were selected for this study. These patients had at least 1 fracture involving the middle or upper third of the face, which led consequently to a fracture of any of the paranasal sinuses of the face (maxillary, ethmoidal, or frontal)

and were grouped according to its fracture sites and associated traumatic SE. There were 458 fractures, divided into 382 fractures of zygomaticomaxillary complex (183 right side, 199 left side), 48 fractures of the maxilla (14 Le Fort I, 14 Le Fort II, 4 Le Fort III, and 16 other fractures of the lateral wall of the maxillary sinus), 16 fractures of the frontal bone, and 12 nasal-orbital-ethmoidal fractures. Data analysis showed 29 cases (6 females, 23 males) of traumatic SE of the face diagnosed by clinical inspection or palpation, with patients ranging in age from 17 to 73 years, with a mean age of 36.71 ⫾ 15.71 years (Table 1). These SE corresponded to a frequency of 7.43% (29 of 390) in our midfacially injured patients. The causes of the injuries that resulted in SE were vehicle accidents (13 cases, 44.83%), assaults (12 cases, 41.38%), falls (3 cases, 10.34%), and work accidents (1 case, 3.45%). Vehicle accidents included

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FIGURE 1. Radiographs of patient 27 (Table 1) sustaining zygomaticomaxillary complex injury with associated compromising of medial orbital wall and frontal sinus. A, Posteroanterior plain radiograph showing radiolucency in the left midfacial area surrounding maxillary, ethmoidal, and frontal sinuses. B, Coronal CT scan demonstrating SE in the left side involving orbital, temporal, and buccal regions. C, Coronal CT scan showing SE in the left side involving the masseteric, pterygoid, temporal, and cervical regions. Brasileiro et al. TSE of Face from Paranasal Sinus Fractures. J Oral Maxillofac Surg 2005.

8 car accidents, 4 bicycle accidents, and 1 motorcycle accident, in which only 2 patients (15.38%) were wearing some safety protective device such as a helmet or a seat belt. The emphysemas were associated with 35 zygomaticomaxillary complex fractures, 2 fractures of the frontal bone, and 7 nasal-orbital-ethmoidal fractures. All of the

patients had at least 1 zygomaticomaxillary complex fracture, associated with another zygomaticomaxillary complex, nasal-orbital-ethmoidal, or frontal fracture in 12 patients, leading to 22 single unilateral periorbital SE, 5 single bilateral periorbital SE, 1 bilateral periorbital, canine, and masseteric SE, and 1 left orbital, masseteric, pterygoid, temporal, and cervical SE (Fig 1).

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Table 2. PARANASAL SINUS INVOLVEMENT IN FACIAL FRACTURES ACCORDING TO THE OCCURRENCE OF SUBCUTANEOUS EMPHYSEMA

lated facial lacerations surrounding the areas of traumatic SE were observed in 8 of the 29 cases (27.59%). STATISTICAL ANALYSIS

Fractured Sinus (Group) (1) Maxillary (2) Ethmoidal (3) Frontal (4) Maxillary ⫹ ethmoidal (5) Maxillary ⫹ frontal (6) Ethmoidal ⫹ frontal (7) Maxillary ⫹ ethmoidal ⫹ frontal Total

Without Subcutaneous Emphysema

With Subcutaneous Emphysema

330 2 7 16 5 0

17 0 0 9 1 0

1 361

2 29

Brasileiro et al. TSE of Face from Paranasal Sinus Fractures. J Oral Maxillofac Surg 2005.

Regarding the sinuses associated with the fracture sites, in 17 cases (58.62%), there were maxillary sinus wall fractures exclusively. In 11 cases (37.93%) the ethmoidal sinus walls were injured, but also associated with maxillary (9) or maxillary and frontal (2) sinus fractures simultaneously. Finally, 1 case (3.45%) had concomitantly maxillary and frontal sinus fractures, without compromising the ethmoidal sinus. Data collection of sinus fractures are displayed in Table 2. All patients were clinically diagnosed with a SE at the first consultation. However, 1 patient evolved an SE following nose blowing, 24 hours after the moment of injury, and then looked for a specialized treatment. One complication was observed during the management of the patients sustaining facial SE. The patient who presented the SE of periorbital, masseteric, pterygoid, temporal, and submandibular regions complained of persistent pain during the first 5 days following trauma in the left periorbital and temporal sites. The facial fractures were treated in 16 cases (55.17%) conservatively, and in the other 13 (44.83%) cases open surgery was instituted. According to the etiology, an open surgery procedure was performed in 53.84% of the vehicle accident patients, 41.66% of assault patients, and none of the falls patient groups. The single work accident caused by a car tire blowout was conducted with open surgery. Signs and symptoms accompanying the SE at the moment of the first attendance were also recorded. These signs and symptoms in order of decreasing frequency were edema (86.21%), bone deformity (79.31%), periorbital and/or subconjunctival ecchymoses (72.41%), pain (62.07%), trismus (37.93%), paresthesia (27.59%), malocclusion (24.14%), hematoma (20.69%), epistaxis (13.79%), displacement of the palpebral fissure (6.90%), and diplopia (3.45%). Corre-

Statistical values for gender prevalence, occurrence of SE based on associations of sinus fractures, the type of sinus involved in SE evolution, and influence of lacerations on etiology were calculated. Data were then imported to BioEstat version 2.0 (Belém, PA, Brazil) for subsequent processing. Chi-square test was applied to compare whether 2 independent samples belong to the same population and, thus, if they keep their rates of occurrence. Fisher’s exact test was also used to calculate the similarity of 2 populations, but was particularly indicated to situations of low scores. The relative risk test could be used on events in which proportions of 2 populations could be obtained. Using this test, one may even speculate the probabilities of a certain event to occur related to another one not exposed to a defined variable. Values of P ⬍ .05 to chi-square and relative risk test, and P ⬍ .01 to Fisher’s exact test were considered statistically significant. The results of independency chi-square test examining the variable gender showed that the differences between these populations (with and without SE) were not significant (P ⫽ .4). Although there was a high discrepancy between the number of males and females who presented a SE (male- female ratio, 3.83: 1), it was statistically compatible (P ⫽ .3) to those showed by all patients sustaining a midfacial fracture in the study (male-female ratio, 5.96:1). With respect to the number of paranasal sinuses involved in the same injury, the groups were displayed in Table 1. Groups 2, 3, and 6 were excluded because of a null value in at least 1 event. Chi-square tests were applied to compare group 1 with group 4 (P ⬍ .0001), group 1 with group 5 (P ⫽ .7), and group 1 with group 7 (P ⫽ .0006). Fisher’s exact test estimated no significant differences between group 4 and group 5 (P ⫽ .6), groups 4 and 7 (P ⫽ .5), and group 5 and 7 (P ⫽ .2). Therefore, patients with concomitant maxillary and ethmoidal sinus fractures and maxillary, ethmoidal, and frontal sinus fractures had significantly higher rates of occurrence of a SE when compared with isolated maxillary sinus fractures. When more than 1 sinus had been involved (groups 2 to 4), an occurrence difference did not seem to exist (all P ⬎ .05). No cases of isolated ethmoidal or frontal sinus fractures diagnosed in this population were associated with SE. Etiologically, the statistics about the type of sinus related to the arising of SE following facial fractures was performed. Ethmoidal sinus could lead to SE in 39.29% (11 of 28) of cases in which fractures disrupted its bone integrity. Frontal sinuses might be

BRASILEIRO ET AL

responsible for SE in 18.75% (3 of 16) and maxillary sinuses could generate SE in 7.61% (29 of 381) of cases. Independency chi-square tests showed a significant difference between maxillary and ethmoidal sinus populations (P ⬍ .0001) and an insignificant difference between maxillary and frontal sinuses (P ⫽ .2). Fisher’s exact test expressed no difference between the ethmoidal and frontal groups (P ⫽ .1). The relative risk test also revealed a significant risk factor (rr ⫽ 5.16; P ⬍ .0001) to ethmoidal sinus fractures when compared with maxillary sinuses regarding the etiology of SE. This means that a SE can arise secondarily from an ethmoidal sinus about 5 times more frequently than from a maxillary sinus. The relative risk test did not show any difference between other groups (P ⬎ .05). Finally, lacerations found in patients with facial fractures associated with paranasal fractures did not influence the occurrence of SE. Chi-square tests found no difference (P ⫽ .9) between rates of 29.62% (8 of 27) and 30.47% (110 of 361) to occurrence of lacerations in cases with and without associated SE, respectively. Thus, no correlation to the occurrence of lacerations, and consequently, no association with the presence of closed fractures involving the paranasal sinuses and development of an SE were found.

Discussion Fractures of the facial skeleton are considered a potential source of SE of the head and neck area. Although relatively rare, it is usually the result of direct trauma to the maxillary sinus, the nasal-orbitalethmoidal complex, and fractures of the zygomaticomaxillary complex involving the lateral wall of the maxillary sinus. These fractures establish communication of the air passages with the orbit and the subcutaneous tissues of the face and eyelids. Particular events may even exacerbate because of a sudden pressure rise within the air passages such as blowing the nose or sneezing.1,2 SE following traumatic injuries of the oral and maxillofacial region has been studied for a long time, but most clinical studies have been in the form of case reports. Although this lesion is well recognized and clearly diagnosed after an appropriate evaluation of a midfacial traumatized patient, some complications may arise following its establishment. Even more, the patterns of presentation and correct maneuvers to avoid its development should be more accurately presented. After midfacial fractures, SE usually occurs during a brief period posttraumatically when air can be forced into the tissues. After this, the escape routes became sealed by blood clots in the sinuses and the fracture sites.13 Lipman et al13 reported a case in which a

1085 patient developed an SE of the face and neck 4 hours after a zygomaticomaxillary closed fracture due to nose blowing, in an attempt to clear his nostrils. However, if the patient’s fracture is of sufficient magnitude, the condition may recur or have a delayed occurrence, and patient should be advised.2,34 Thus, SE may also arise later, as reported by Von Arx and Gilhooly,15 who reported on an SE appearing in the midface 7 years after an orbital floor fracture. In our study, just 1 patient presented without an SE immediately after the moment of injury. Even so, this patient’s SE arose 24 hours later from an undisplaced zygomaticomaxillary complex fracture due to blowing the nose. It is not uncommon to observe emphysemas in zygomatic fractures, particularly after blowing the nose, and subsequently increasing the pressure inside the upper airways.2,23 Our study showed a TSE prevalence of 7.43% (29 of 390) in our midfacially injured patients, which might be representative of such a low rate. Although SE is more commonly seen on CT, our patient’s diagnoses of TSE were performed based on clinical signs. This parameter was established while attempting to analyze only the facial TSE with major clinical involvements during the physical examination. Otherwise, we would have found a larger amount of insignificant TSE associated with sinus fractures, which would not lead to alterations in the patients’ clinical status. TSE usually appears in the periorbital subcutaneous tissues rather than within the orbit itself. In our study, 1 case presented a periorbital and intraorbital emphysema associated with a masseteric, pterygoid, temporal, and cervical SE. However, the patient did not have globe function (motility or visual acuity) compromised by the trauma. Controversially, Monaghan and Millar22 reported a pure blowout fracture with intraorbital emphysema which caused temporary double vision and pain. The involvement of the interior contents of the orbit by emphysema might represent 1 situation in which to institute an urgent surgical procedure to avoid orbital tissue damage, especially when an increased orbital pressure is present, and consequently, the risk of vision loss is high.22 In our institution, exploration of the orbital contents due to ocular function compromise, associated or not with TSE, is only performed after an ophthalmologist evaluation. When dealing with facial fractures that involve the orbit, prompt consultation with an ophthalmologist is indicated.22,33,34 Regarding its etiology, based on plain radiographs and CT, we have found that the prevalence of ethmoidal fractures (nasal-orbital-ethmoidal complex and medial orbital wall fractures) in this sample was lower than maxillary fractures. However, statistical analysis showed that although medial orbital wall/ethmoidal

1086 sinus fractures are less frequent, they are associated more frequently with TSE than maxillary sinuses fractures. These results corroborate the assertion that medial orbital fractures involving the ethmoidal sinuses were the main reason for periorbital SE in zygomatico-orbital maxillary complex fractures34 or midfacial injuries.33 The signs and symptoms associated with SE of the paranasal region followed the characteristics of zygomaticomaxillary complex33 or midfacial fractures.34 Ellis et al36 analyzed 2,067 cases of zygomatico-orbital fractures and observed that the range of frequency of signs and symptoms depended upon the type and severity of the fracture. Our sample showed that edema (85.18%), bone deformity (81.48%), periorbital and/or subconjunctival ecchymoses (70.37%), pain (66.67%), and trismus (40.74%) were the most prevalent features. When present, crepitation can be alarming to the patient although SE of the face does not, by itself, present any serious prognosis. TSE generally disappears spontaneously within a few days without treatment.34,35 Nevertheless, air forced into the tissues from the sinuses may carry with it infected materials presented in the antrum and thus precipitate an acute cellulitis.13,20 Some other grave conditions may be found in the literature due to extensive emphysema. SE may cause pain and a mass obstruction to retinal perfusion with partial or total loss of vision.2,7,17 More recently, 1 article30 reported an unusual surgical cervicofacial emphysema that caused distortion of adjacent nerves with temporary disturbances of the lower 4 cranial nerves. Decreased gag reflex, dysphagia, hoarseness of the voice, limited abduction of the arm, and tongue deviation on protrusion was observed. More seriously, emergency situations following spread of air into the neck can cause respiratory difficulty and require tracheostomy,2,8 while migration to the thorax and mediastinum may result in compromised respiratory and cardiac function and even death.3,5,6,11,16,18,19,21,23 In our sample, only 1 mild complication secondary to SE was seen during the treatment period. It consisted of persistent pain noted by 1 male, particularly in the periorbital and infra-temporal region. This patient was representative of the most extensive SE of the study, with introduction of air into the left fascial planes of upper, middle, and lower thirds of the face, temporal and cervical regions. Such expressive air diffusion was directly responsible for the patient’s discomfort, even though a left displaced zygomaticomaxillary fracture was diagnosed. Choosing the treatment for a midfacial injury is challenging to the oral and maxillofacial surgeon and staff. The treatment choice should be based on clinical and radiographic findings, reaching for esthetic and functional abnormalities.33 As shown earlier, SE of the face is associated with critical fractures of the facial skeleton in many situations, which demand un-

TSE OF FACE FROM PARANASAL SINUS FRACTURES

compromising care. As a result of the air expansion into the tissues, surgical access and the workability of tissues becomes even worse in such a demanding area. Thus, one should consider waiting for regression of the facial SE before performing open surgery. In our study, all 13 cases were operated just before resolution of the SE. As long as SE remains only a few days, it should not compromise the treatment of midfacial fracture.34 Therefore, it is important to warn patients about nose blowing, coughing, sneezing, and mucous plugging during the postinjury and postoperative period.1,23,29 Special attention should be given to postoperative support care, which may increase subcutaneous air diffusion in patients who underwent open surgery.18 Oliver and Coulthard32 also suggested that it would be prudent to check the medical history of asthmatic patients to assess if they used their own peak flow meter and, if so, to discourage them from using it postoperatively. None of our patients developed postoperative SE or a complication following its establishment. We believed that the severity of our SE sample and the support care provided during its entire follow-up period were responsible for these outcomes. In conclusion, we verified that clinical signs of TSE of the face associated with paranasal sinus fractures are an uncommon finding (7.43%). The primary etiologic site of TSE is the ethmoidal sinus, with higher prevalence for the periorbital region. Characteristically, TSE was predominant in males and adults, related to vehicle accidents and assaults, and associated with other midfacial fractures. Complications arising from TSE were rare, and warning about care was paramount during patients’ observation. Acknowledgment The authors thank Prof Gláucia Maria Bovi Ambrosano for statistical assistance.

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