Med Journal July 2020 Final | Page 16

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