[Soft tissue emphysema in spontaneous pneumothorax. Features of medical approaches]. / Massivnaya emfizema myagkikh tkanei pri spontannom pnevmotorakse. Osobennosti lechebnoi taktiki.

Soft tissue emphysema (including subcutaneous emphysema) is common in pneumothorax. In most cases, this condition is of little clinical significance and regresses under standard medical procedures. However, progressive soft tissue emphysema poses a threat to the patient's life in case of compression of the upper respiratory tract in some cases. The world literature describes various approaches to the treatment of these patients. Standard medical care for progressive soft tissue emphysema following pneumothorax is pleural drainage with active aspiration. Despite unequivocal treatment tactics, this may not be enough in case of massive air release. Surgical treatment may be accompanied by surgical and anesthetic difficulties including difficult intubation. The authors present persistent tension pneumothorax and soft tissue emphysema, features of surgical and anesthetic management, as well as current treatment options.

Post-extubation use of high-flow nasal oxygenation induces upper airway leak and intrathoracic sepsis after successful Bentall procedure: A case report.

RATIONALE: In recent few years, high-flow nasal oxygenation (HFNO) has been widely used for management of acute hypoxemic respiratory failure and during postextubation periods, including after endotracheal intubation general anesthesia (ETGA). However, HFNO generates positive pressure in the injured airway following removal of endotracheal tube may cause airway leaks. This is the first case report of severe airway leak syndrome following postextubation use of HFNO in surgical patients. PATIENT CONCERNS: This case report describes a 75-year-old female with critical aortic stenosis who underwent an emergency Bentall procedure. HFNO (flow rate of 45 L/min) was applied after weaning from mechanical ventilation and removal of the endotracheal tube. DIAGNOSES: At 6 hours after HFNO application, subcutaneous emphysema in the neck bilaterally and face was noted, and the emphysema extended into the supraclavicular regions. INTERVENTIONS: The HFNO cannula was removed soon after and the patient was re-intubated with an endotracheal tube the following day due to progressive respiratory insufficiency. Unfortunately, the patient general condition deteriorated, as the subcutaneous air collections progressed into deep tissue infections of the neck, mediastinal abscesses, and left-sided empyema. Patient received surgical interventions repeatedly to drain the mediastinal abscess and empiric antimicrobial therapy was given. OUTCOMES: The patient passed away about 2 months later due to uncontrollable sepsis. LESSONS: Air leaks in the upper airway can occur during the use of post-extubation HFNO use, and the resulting subcutaneous emphysema can progress to severe intrathoracic infections in surgical patients who have a sternotomy wound. Therefore, HFNO-induced subcutaneous emphysema should be treated more aggressively in open thoracic or sternotomy surgeries to prevent the development of intrathoracic sepsis.

Decompression Technique Using Subcutaneous Angiocatheter Insertion to Relieve Extensive Subcutaneous Emphysema: A Case Report.

BACKGROUND: Trauma, pneumothorax, complication of surgery, infection, or malignancy can cause subcutaneous emphysema and although most subcutaneous emphysema cases are self-limited, extensive subcutaneous emphysema can lead to a compromised airway and cardiovascular system. In this report, we described a successful treatment strategy in which subcutaneous angiocatheter insertion was used to relieve the pressure of extensive subcutaneous emphysema. CASE REPORT: An 83-year-old man was received at the emergency department (ED) for recurrent pneumothorax and extensive subcutaneous emphysema. Six 18-gauge angiocatheters were inserted under the thoracic subcutaneous tissue and a noticeable improvement was seen 3 h after angiocatheter insertion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Subcutaneous angiocatheter insertion may be a safe and uncomplicated decompression technique to relieve extensive subcutaneous emphysema, particularly in the ED.

[Gentle Method to Elevate Left Liver Lobe in Robot Assisted Gastrectomy].

Robot-assisted gastrectomy with the Davinci XiTM has been performed in our department since August 2019. This technique requires elevation of the left liver lobe. In order to prevent perioperative liver injury and expansion of postoperative subcutaneous emphysema, we use a silicone disc(HAKKO MEDICAL Co., Ltd.)and thread to elevate the liver. After docking the Davinci system, we move the needle as follows:(ⅰ). left side peritoneum near the left triangular ligament, (ⅱ). silicone rubber(, ⅲ). center of crus(, ⅳ). silicone rubber(, ⅴ). hepatic cirrus, and(ⅵ). right side peritoneum. Both ends of the thread are guided out of the abdominal cavity from both hepatic circumflex by end-close, forming a V-shape with the center of crus at the bottom, which provides a stable and effective view of the liver. Fifty-three cases were performed after introduction of this elevation technique. Median AST and ALT on postoperative day 1 were 37(14-1,556)IU/L and 30(10- 1,676)IU/L, respectively, although small subcutaneous emphysema confined to the anterior chest and upper abdominal wall was observed in 2 patients(3.8%). No cases of extensive subcutaneous emphysema involving the neck or extremities were observed. This elevation technique protects the liver and may reduce the incidence of postoperative subcutaneous emphysema.

Perioperative Management of a Patient With Tongue Cancer Who Developed Pneumomediastinum Following Tracheostomy Performed to Secure the Airway.

Prior to a scheduled operation for a 45-year-old male patient with tongue cancer, a tracheotomy performed under intravenous sedation to prevent asphyxia due to extensive bleeding resulted in pneumomediastinum and subcutaneous emphysema. The planned operations were postponed until reduction of the pneumomediastinum was confirmed. During operation, airway pressure was kept low to prevent tension pneumomediastinum along with a sufficient depth of anesthesia, controlled analgesia, and continuous administration of muscle relaxants. Postoperatively, sedation was used to avoid stress and complications with the vascular anastomosis site. In this case, air leakage into the soft tissues was one of the possible causes of the event associated with increased airway pressure. Although the incidence of such complications is relatively low, caution should be exercised after tracheostomy.

Free air after laparoscopic hysterectomy; from sigmoid perforation to upper airway compromise: a case report.

BACKGROUND: Free air after laparoscopic hysterectomy is a common finding; in rare cases, free air represents gastrointestinal perforation, requiring emergency laparotomy. Ectopic air localizations after pneumoperitoneum have been reported in various laparoscopic surgical techniques. Delayed diagnosis of visceral perforation is associated with high mortality rates. CASE PRESENTATION: We present a white Caucasian female in which dysphonia due to air entrapment in the cervical area, pneumomediastinum and pneumothorax, occured afterlaparoscopic hysterectomy. CONCLUSIONS: Upon mobilization of the patient, air from sigmoid perforation moved cephalad. Through the same path, pneumoperitoneum, causes subcutaneous emphysema in the neck and face, pneumomediastinum and pneumothorax.

Bedside Transcervical-Transtracheal Postintubation Injury Repair in a COVID-19 Patient.

Severe acute respiratory syndrome coronavirus 2 disease 2019 (COVID-19) has rapidly spread worldwide since December 2019. An acute respiratory distress syndrome develops in a relevant rate of patients, who require hospitalization. Among them, a nonnegligible rate of 9.8% to 15.2% of patients requires tracheal intubation for invasive ventilation. We report the case of a pneumomediastinum and subcutaneous emphysema developing in a COVID-19 patient secondary to postintubation tracheal injury. The management of COVID-19 patients can be challenging due to the risk of disease transmission to caregivers and epidemic spread. We performed a bedside tracheal injury surgical repair, after failure of conservative management, with resolution of pneumomediastinum and subcutaneous emphysema and improvement of the patient's conditions.

Extensive Post-Traumatic Surgical Emphysema Exacerbated by Cocaine Insufflation.

Surgical emphysema (SE) is characterized by air in the soft tissues causing a crackling sensation on palpation. In oral and maxillofacial surgery, it might occur using conventional air-driven dental hand pieces, as a complication of trauma and with cocaine insufflation.The subcutaneous air may travel through tissue planes causing cervicofacial emphysema, pneumothorax, and pneumomediastinum. It may carry bacteria and potentially lead to cellulitis or necrotizing fasciitis.The SE is usually a self-limiting entity requiring analgesia, close observation of the airway, occasionally prophylactic antibiotics, and rarely steroids. Although, the consensus on antibiotic and corticosteroid therapy is unclear.Here presented an unusual and extensive presentation of surgical emphysema. A 29 years old male presented with emphysema following a left orbital-zygomatic complex fracture and following intranasal cocaine insufflation. It extended from the temple to the parotid region, down into the neck and into the mediastinum. No surgical intervention was required. The patient was discharged after 24 hours of observation with a week-long course of co-amoxiclav antibiotics and no corticosteroids administration.Typical instructions following facial bone fractures are to avoid nose blowing because of the risk of SE, however, avoidance of drug habits is rarely considered. This case report highlights the importance of tailored advice to this particular patient cohort.

Orbital Blowout Fracture and Orbital Emphysema caused by Nose Blowing.

A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted.

Subcutaneous emphysema and pneumomediastinum in child with asthma revealing occult foreign body aspiration: a case report.

BACKGROUND: Exacerbations of asthma constitute the most common cause of pneumomediastinum and subcutaneous emphysema in children. Foreign body aspiration is a rare cause of pneumomediastinum and subcutaneous emphysema. Foreign body aspiration leading to the occurrence of pneumomediastinum in a child with asthma may go unnoticed and be wrongly attributed to asthma, which leads to delayed diagnosis as well as to life-threatening and long-term complications. CASE PRESENTATION: We describe a case of a 6-year-old Moroccan boy with asthma who was admitted to our emergency department for acute dyspnea and persistent dry cough. The patient was initially treated as having acute asthma exacerbation. Owing to insufficient clinical and radiographic improvement with asthma treatment, a rigid bronchoscopy under general anesthesia was performed. A pumpkin seed was removed from the left main bronchus. Clinical and radiographic improvement was achieved after foreign body extraction. CONCLUSIONS: This case emphasizes that the possibility of foreign body aspiration should always and carefully be considered by the emergency physician when faced with a child with asthma presenting with pneumomediastinum and subcutaneous emphysema as an important differential diagnosis even in the absence of a history of foreign body aspiration.

A 73-Year-Old Man With Progressive Whole Body Subcutaneous Gas After Pleural Catheter Removal.

CASE PRESENTATION: A 73-year-old man presented to the ED of an outside hospital with asymptomatic chest wall swelling 10 h after discharge from our hospital. Four days earlier, he had presented to our hospital with increased dyspnea, cough, and sputum production. His history was notable for severe COPD with bullous emphysema. Chest imaging demonstrated bilateral opacities and a collection of gas and liquid in the major fissure of the left lung. A catheter was placed into the collection of gas and liquid under imaging guidance. After 4 days, the catheter was removed without event and the patient was discharged from the hospital with an extended course of antibiotics. Imaging performed in the ED revealed gas in the tissues of the chest wall and no evidence of a pneumothorax. He was transported back to our hospital by helicopter.

Progressive subcutaneous emphysema of unknown origin: a surgical dilemma.

Objective: Subcutaneous emphysema can be an alarming sign of a necrotizing soft tissue infection. However, non-infectious etiologies exist that can be treated conservatively. This case report describes a subcutaneous emphysema of unknown origin and highlights the importance of distinguishing these clinical entities. Methods: We present a 17-year old female with pain and subcutaneous emphysema of the left arm. There were no systemic symptoms. Inflammatory parameters were slightly elevated. Computed tomography (CT) scan of the chest excluded intrathoracic abnormalities. Despite antibiotic treatment, the pain increased and the emphysema extended. Necrotizing fasciitis was feared. A surgical exploration was performed and hyperbaric oxygen therapy was started. Results: Intraoperatively, puncture marks were identified on the left arm. Air noticeably escaped, but normal, unaffected tissues were identified and microbiological cultures remained negative. We observed a good clinical evolution. Conclusion: The lack of apparent causes, the unexplained puncture marks and psychiatric comorbidity suggests the possibility of subcutaneous emphysema due to factitious manipulations. Patients with subcutaneous emphysema who remain clinically stable, have minimal pain and no significant inflammatory changes could be treated conservatively. Close clinical monitoring is essential to avoid delayed intervention in case of a necrotizing soft tissue infection.

Enfisema subcutáneo tras colangiopancreatografía retrógrada endoscópica / Subcutaneuos emphisema after endoscopic retrograde cholangio-pancreatography

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Bowel perforation presenting with acute abdominal pain and subcutaneous emphysema in a 14-year-old girl with an abandoned distal peritoneal shunt catheter: case report.

The authors report the case of 14-year-old girl with a history of myelomeningocele and previously shunt-treated hydrocephalus who presented with right-sided abdominal pain and subcutaneous emphysema that developed over a 1-week period. A CT scan of the patient's abdomen revealed a retained distal ventriculoperitoneal (VP) catheter with air tracking from the catheter to the upper chest wall. Given the high suspicion of the catheter being intraluminal, an exploratory laparotomy was performed and revealed multiple jejunal perforations. The patient required a partial small-bowel resection and reanastomosis for complete removal of the retained catheter. Six other similar cases of bowel perforation occurring in patients with abandoned VP and subdural-peritoneal shunts have been reported. The authors analyzed these cases with regard to age of presentation, symptomatic presentation, management, morbidity, and mortality. While there was 0% mortality associated with bowel perforation secondary to a retained distal VP catheter, the morbidity was significantly high and included peritonitis and small bowel resection.

[Drainage for Subcutaneous Emphysema after Pulmonary Resection].

Severe subcutaneous emphysema sometimes develops after pulmonary resection. We report our management of ten patients who were treated with subcutaneous Penrose drainage. Water seal test at chest closure showed no air leakage in 5, and a small amount in 5. Chest X-ray at the progression of massive subcutaneous emphysema showed no obvious pneumothorax in 2, and slight apical pneumothorax in 8. Subcutaneous emphysema developed after removal of chest tubes in 6, and before removal in 4. Subcutaneous drains were inserted at the midclavicular line or the side chest in 8, and both in 2. Subcutaneous emphysema improved immediately after subcutaneous Penrose drainage with active compressive massage. Subcutaneous penrose drainage is easy and useful for relieving massive subcutaneous emphysema.

Repair of a posterior perforation of the trachea following thyroidectomy with a muscle transposition flap.

Tracheal perforation is a rare postoperative complication of total thyroidectomy. While previously documented cases have been reported in the anterior aspect of the trachea after a total thyroidectomy, we report what we believe is the first documented case of a perforation in the posterior aspect of the trachea. Our patient was a 29-year-old woman who presented with symptoms of tracheal impingement in the context of a right-sided goiter that subsequent investigation found to be three benign colloid nodules. Fourteen days after her total thyroidectomy, she presented with surgical emphysema surrounding the wound. Computed tomography identified a 2.5-mm defect in the right posterior lateral trachea, posterior to the cartilaginous ring. The defect failed to seal spontaneously, and after 48 hours, the patient remained symptomatic. During reexploration, the defect was successfully repaired with a myovascular transposition flap in conjunction with Tisseel tissue-bonding agent. This technique has the potential to be applied in future intraoperative and postoperative cases of tracheal perforation.

Blunt maxillary fracture and cheek bite: two rare causes of traumatic pneumomediastinum.

Subcutaneous facial emphysema is a well-known consequence of oral and maxillofacial traumatic injury. In some rare cases, the subcutaneous air collection could spread through the retropharyngeal and paralatero-cervical spaces, reaching the mediastinum. This clinical entity is known as pneumomediastinum and represents a severe and, sometimes, life-threatening condition. Other reported causes of pneumomediastinum are esophageal and tracheal traumatic or iatrogenic rupture. Finally, the so-called spontaneous pneumomediastinum is caused by a sudden increase in alveolar pressure and is usually seen in young men. We present two cases of pneumomediastinum as a consequence of unusual traumatic damage of orofacial tissues, followed by repeated sneezing and Valsalva maneuver.