Case Study
by Anil Kopparapu MD 1 ; Diane Jarrett EdD 1 ; Gitanjali Bajaj MD 2 ; Shashank Kraleti MD 1
1
Department of Family and Preventive Medicine; 2 Department of Diagnostic Radiology, UAMS
Iatrogenic Cervicothoracic Subcutaneous
Emphysema, Pneumomediastinum
Following a Dental Treatment Procedure
ABSTRACT
Background: Subcutaneous emphysema
and pneumomediastinum are commonly
caused by traumatic injury or iatrogenic
injury such as a surgical procedure
of the respiratory and alimentary tracts. It
can be caused by the infections from gas-foaming
bacteria or during dental procedures while
using high-speed air turbine drills and/or laser
therapy, or spontaneously.
Case summary: A 66-year-old female presented
with cervicothoracic subcutaneous emphysema,
pneumomediastinum that occurred
during a dental procedure involving a highspeed
air turbine drill and laser therapy.
Conclusion: Surgical procedures in the
oral cavity can lead to the development of emphysema
and pneumomediastinum, especially
when air turbine dental drills and/or lasers are
used. Treatment is usually supportive care. Clinicians
must recognize these conditions early
to avoid life-threatening complications.
Early recognition of this
condition is essential
in preventing lifethreating
complications
such as airway
obstruction, sudden
cardiac arrest, and
respiratory failure.
KEYWORDS
Cervicothoracic emphysema, Pneumomediastinum,
dental procedures, dental highspeed
air turbine drill, dental laser treatment,
Tooth extraction
INTRODUCTION
Subcutaneous emphysema is defined as
presence of air or gas underneath the skin.
Pneumomediastinum is defined as air or gas
in the mediastinum. 1 These are uncommon
conditions that occurs when air leaks from any
part of lung or airways in to the skin and the
mediastinum. Subcutaneous emphysema is
appreciated by a palpable crepitus on physical
exam, 2 usually diagnosed by conventional
chest x-rays; however, non-contrast CT of the
chest is more sensitive if only low levels of air
accumulate. Usually, supportive care with rest,
antibiotics, and analgesia is adequate.
CASE REPORT
A 66-year-old female presented to the emergency
department with sudden onset of chest
pain and neck pain with swelling on both sides
of the neck. This occurred while she was undergoing
a prolonged dental treatment in which her
dentist used a high-speed air turbine dental drill
and laser equipment. She underwent right lower
dental bridge removal over the second premolar,
first and second molar teeth, and gingivectomy
during her dental procedure. She had a history
of hypertension, hyperlipidemia, insomnia, and
anxiety. She did not have any pre-existing lung
disease or chest problems. Her medications included
trazodone, simvastatin, cholestyramine,
aspirin, and duloxetine. She denied history of
smoking, alcohol intake, or recreational drug use.
Vital parameters revealed a heart rate of 71 beats
per minute, blood pressure of 157/76 mmHg, a
respiratory rate of 18 breaths per minute, with a
peripheral capillary oxygen saturation of 100%
on room air and a temperature of 97.9 0 F. Physical
examination revealed swelling and crepitation
over both sides of the neck, the right shoulder,
and the right chest wall. Oral examination revealed
no significant wounds or lacerations.
No signs of hematoma were noticed. Her heart
sounds and breath sounds were normal. Labs
showed mildly elevated white blood cell count
(13.48 K/uL). All other cell counts, renal function
tests, troponin, and Electrocardiogram were normal.
Chest x-ray showed extensive subcutaneous
air within the bilateral neck spaces, anterior chest
wall, and pneumomediastinum (Figure 1, 2). CT
scan of neck, chest revealed extensive subcutaneous
air within the bilateral neck spaces, anterior
chest wall, mediastinum and small volume
bilateral apical pneumothorax. No radiological
findings of rib fractures or organ rupture or mediastinitis
were noted. She was started on prophylactic
broad-spectrum antibiotics, vancomycin,
and piperacillin-tazobactam and was admitted
to the family medicine team for further management.
Her symptoms started to improve within
24 hours, and she was discharged to home on
oral clindamycin. Her symptoms completely resolved
in one week.
DISCUSSION
Subcutaneous emphysema and pneumomediastinum
are commonly caused by traumatic
injury or iatrogenic injury such as any surgical
procedure of the respiratory and alimentary
tracts. 1 It can be caused by the infections from
gas-foaming bacteria or during dental procedures
while using high-speed air turbine drills
and/or laser therapy or spontaneously. 2 Air compression
and laser use during dental procedures
can cause air to be forced down into the mediastinum.
The roots of the first, second, and third
molars communicate directly with the sublingual
and submandibular spaces, that are communicated
to mediastinum thru pterygomanidular,
parapharyngeal, and retropharyngeal spaces. 1
16 • The Journal of the Arkansas Medical Society www.ArkMed.org