Case Report

Fifty-year-old female with facial subcutaneous emphysema: a case report

Abstract

Subcutaneous emphysema in itself is a Benign condition. However, when present secondary to trauma, it may indicate a more serious problem. We report a patient with subcutaneous emphysema secondary to trauma sustained during a Generalized seizure. It is believed that the source of the air in the tissue was from a minor laceration below and into the patient’s nose without any fracture of the underlying bones or sinus involvement.

There have been several case reports of facial subcuta- neous emphysema in the literature [1-7]. These have generally involved an iatrogenic penetration secondary to a procedure or have been associated with a traumatic fracture. Subcutaneous emphysema in itself is considered a benign condition [8]. However, it can indicate a more serious underlying problem such as tracheobronchial injury, pneu- mothorax, Tension pneumothorax, and pneumomediastinum. The treatment of the subcutaneous emphysema is to address the underlying or causal issue.

A 50-year-old menopausal female presented to the emergency department (ED) with a small laceration to the right side of her nose secondary to trauma sustained during an unwitnessed seizure. The laceration was not actively bleeding. This incident had occurred 10 hours previously, and she had no recollection of the circumstances. She believes she fell and struck her nose on the fireplace. She had a medical history notable for seizures for 2 years, bipolar disorder, hypothyroidism, hypercholesterolemia, migraine headaches, and gastric ulcers. She had one shoulder surgery. She took several medications including nortriptyline, chlorpromazine, paroxetine, Stelazine, Lamictal, lovastatin, and levothyroxine. She stated she had an allergy to penicillin

that causes a mild rash.

She was unemployed, denied use of either alcohol or drugs, and lived at home with her husband.

Her review of systems was unremarkable except for the complaint of rhinorrhea, epistaxis, and the laceration/ abrasion on the right side of her nose. She denied any numbness, tingling, weakness, headache, confusion, nausea, vomiting, fevers, or vision changes.

Her vital signs were temperature of 35.8?C, blood pressure of 99/65, heart rate of 86, and respiratory rate of 20. The result of her physical examination was unremark- able except for some clotted blood in her right nare, a laceration that went through her right nare and nasal septum (estimated a total of 2 cm in length), facial swelling around the bridge of her nose along with subcutaneous emphy- sema, tenderness at the bridge of her nose, and a small amount of clear rhinorrhea from the right nare. Her pupils were equal and reactive to light. Her extraocular muscles were intact as were Cranial nerves 2 through 12. She had normal reflexes in her upper extremities and mild equal hyperreflexia (3+/4) bilaterally in her lower extremities with equal strength bilaterally on all her extremities (5/5). She was alert and oriented to person, place, and time. She had no shortness of breath, and her lungs were clear to auscultation bilaterally. She had no chest wall tenderness,

no bony deformity, and no palpable crepitus.

Because of the laceration, tetanus prophylaxis in the form of an intramuscular (0.5 mL) diphtheria-tetanus toxoid injection was administered. In addition, cefazolin 1 g IM was given prophylactically.

One concern in this case was the clear rhinorrhea that potentially could have been cerebrospinal fluid and the etiology of the air in the subcutaneous tissue. It was thought that a fracture to one of the sinuses, facial bones, or cranium could be the source of the air and clear rhinorrhea, so a computed tomography of the head was performed (Fig. 1). A pneumothorax and pneumomediastinum were both in the differential as well, so a chest x-ray was also requested. The computed tomographic image demonstrated a significant amount of deep tissue emphysema on the face and left anterior neck without a fracture being discerned (Fig. 2). In addition, it showed no intracranial abnormality. The chest x- ray film showed no rib fractures, pneumothorax, pulmonary contusion, or subcutaneous air in Soft tissues or mediastinum. Neither test provided any insight as to the potential nidus of the subcutaneous emphysema.

Oral and maxillofacial surgery (OMFS) was then consulted to better understand the etiology of the subcuta- neous emphysema. They reviewed the imaging, discussed the case, and sutured the nasal laceration. Their recommen- dation included clindamycin for prophylaxis against infec- tion, pain medications, and a follow-up in 5 days at their clinic. After discussion between the OMFS and the ED

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Fig. 1 CT of the head and neck showing subcutaneous air tracking into the neck.

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Fig. 2 CT of the face showing subcutaneous air tracking through the left side of the face.

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teams, it was felt that the facial laceration was the likely source of the subcutaneous emphysema.

She was discharged home with specific instructions to return if she developed a fever, signs of infection, excessive bleeding, headaches, neck pains, shortness of breath, or chest pain. She was given a follow-up appointment scheduled with OMFS 5 days later and a 10-day course of oral clindamycin.

The exact prevalence of subcutaneous emphysema is difficult to ascertain, as the etiology for the different underlying causes is typically examined more carefully. This entity has been identified as being more commonly caused by traumatic thoracic injury.

The typical pathophysiology of subcutaneous emphy- sema is that air enters the tissues either extrapleurally or intrapleurally [8]. With an extrapleural lesion in the tracheobronchial tree, ambient air is able to enter the mediastinum and soft tissues of the anterior neck, thus causing a pneumomediastinum. With the intrapleural hole or tear, a pneumothorax is created by air escaping from the lung through the visceral pleura and into the pleural space. From there, the air traverses from pleural space through the parietal pleura into the thoracic wall and associated soft tissue. The literature also discusses subcutaneous emphysema being caused by traumatic laceration, for example, iatrogenically induced penetrating trauma during Dental procedures or blunt orbital fractures. There is even one case that discusses a cheek bite causing this phenomena [1-7].

Subcutaneous emphysema that is localized over the chest wall after blunt trauma should raise the clinical suspicion of a traumatic pneumothorax, whereas subcutaneous emphysema located over the clavicles and anterior neck should raise clinical suspicion of pneumomediastinum. In either case, the risk of progressive leaking of air into the pleural space raises the specter of tension pneumothorax, which is an emergent life-threatening problem. The air trapped in the tissues can traverse cephalad into the face creating facial swelling.

Pneumopericardium may also occur. Air is introduced by the mechanisms discussed previously and travels through the mediastinum into the pericardial sac. This has the potential to cause a life-threatening pneumopericardium or a cardiac tamponade by limiting ventricular filling and causing hemodynamic instability.

The sequelae of the Underlying etiology of subcutaneous emphysema can be the most serious. Subcutaneous emphysema in itself is a benign condition that will resolve over time as the ambient air within the tissues is resorbed. Pneumothorax, tension pneumothorax, and pneumopericar- dium may occur after Penetrating or blunt trauma to the chest or neck.

The symptoms of a pneumothorax include chest pain, pleuritic chest pain, hyperresonance on the affected side, and shortness of breath. Imaging that aids in diagnosis includes a chest x-ray that will show a white pleural line and absence of vascularization to the periphery. A lateral decubitus film is preferred as it will demonstrate a pneumothorax with only 5 mL of air present. An upright film may show a

pneumothorax with the presence of 50 mL of air, whereas supine image may show one with 500 mL of air.

The signs of a tension pneumothorax are significant dyspnea, tracheal deviation to the unaffected side, distention of the neck veins, hyperresonance on the affected side, and Hemodynamic compromise. Treatment of a tension pneu- mothorax is an emergent needle decompression followed by a tube thoracostomy.

Treatment of a pneumothorax requires a tube thoracost- omy if it is large enough, expanding in size, or compromising cardiopulmonary function. Typically, this is seen with a Spontaneous pneumothorax, an iatrogenic pneumothorax, barotrauma (eg, a pneumothorax because of a ventilator), a tension pneumothorax, and penetrating chest trauma.

Pneumopericardium is addressed by pericardial Needle aspiration if clinical signs and symptoms of cardiac tamponade are present. These include hypotension, dis- tended neck veins, Hamman crunch, and muffled heart sounds. The Hamman crunch is crackling or crunching sound noted with cardiac auscultation.

The case presented appears unique in that the etiology of the facial swelling observed was caused by a blunt force that created a laceration through which the subcutaneous emphysema originated from the ambient air. There were no fractures of any bones and no apparent barotrauma.

Gerald W. Beltran DO Mark D. Lopez MD

Department of Emergency Medicine Medical College of Georgia, Augusta, GA E-mail address: [email protected]

doi:10.1016/j.ajem.2007.11.002

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