CLINICAL STUDY

Cervical Subcutaneous Emphysema and Pneumomediastinum After Septorhinoplasty Eun Sung Kim, MD, Ju Wan Kang, MD, Chang-Hoon Kim, MD, PhD, and Jae Min Hong, MD Abstract: Cervical and facial subcutaneous emphysema is mainly caused by maxillofacial trauma or head and neck surgery. There are only 2 cases of subcutaneous emphysema after septorhinoplasty in the English literature. We report a case of subcutaneous emphysema and pneumomediastinum after a septorhinoplasty. A healthy 35-year-old man with nasal obstruction and dissatisfaction with the shape of his nose was referred to our outpatient clinic. The patient had a septorhinoplasty including bilateral medial and lateral osteotomy under general anesthesia. On the fifth day after the surgery, the patient visited the emergency department with swelling and pain in the right submandibular area and cheek. On computed tomographic (CT) scans, air was observed in the right temporal space, masticator space, submandibular space, and superior mediastinal space. He was immediately hospitalized for administration of intravenous antibiotics and bed rest. On the fifth day after the hospitalization, follow-up CT scans were performed. Subcutaneous emphysema and pneumomediastinum were markedly decreased. The patient was discharged on the fifth day. Key Words: Subcutaneous emphysema, mediastinal emphysema, rhinoplasty (J Craniofac Surg 2014;25: 533–534)

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ubcutaneous emphysema is defined as the abnormal presence of air or other gases in the subcutaneous tissue.1 Cervicofacial subcutaneous emphysema is mainly caused by maxillofacial trauma, head and neck surgery, dental extraction, general anesthesia, as well as coughing or habitual performance of valsalva maneuver.2,3 In most patients, treatments of subcutaneous emphysema are simple bed rest and close observation.2,3 Although there are many reports of subcutaneous emphysema after maxillofacial trauma, head and neck surgery, and dental extraction, there are only 2 cases of subcutaneous emphysema after septorhinoplasty in the English literature.1,4 We report a case of postoperative subcutaneous emphysema and pneumomediastinum after a septorhinoplasty.

During the preoperative evaluation, he was diagnosed with allergic rhinitis, septal deviation, and external nose deviation. Results of preoperative laboratory examination and chest x-ray were completely normal. We planned to do septorhinoplasty under general anesthesia. On physical examinations, the external nose was deviated to the right side. Bony portion and cartilage portion of septum were deviated to the right side. Inverted V-shaped columellar incision and marginal incision were performed, and supraperichondral flap was elevated along the lower lateral cartilage and upper lateral cartilage. After that, subperiosteal flap of the nasal bone was elevated and septoplasty was performed. Septal extension graft and spreader graft on the left side were performed with autologous cartilages. Medial and lateral osteotomies were carried out via lateral osteotomy incisions right above the inferior turbinate. After the procedure, Merocel packing was done and Denver splint was applied. Immediate postoperative complication was not noted. On the second day after the surgery, the nasal packings were removed and the patient was discharged on the third day. On the fifth day after the surgery, the patient visited the emergency department with swelling and pain on the right cheek and submandibular area. The patient complied to our advice on not to blow his nose. However, the patient sneezed several times after being discharged. Physical examination results revealed significant soft tissue swelling with a tactile crepitus on palpation. The patient was hemodynamically stable, and lung sound was clear. Laboratory blood tests revealed no abnormal findings. Endoscopic examination results showed that the intranasal wound was healing well and that the upper airway was patent. Radiographs of the lateral side of the neck showed an emphysema on the right side of the upper neck (Fig. 1). Computed tomography was immediately performed to determine the extent of the emphysema. On CT scans, air was observed in the right temporal space, masticator space, submandibular space, and superior mediastinal space (Fig. 2). To relieve the severe pain and prevent the subcutaneous emphysema from expanding, he was immediately

CLINICAL REPORT A healthy 35-year-old man with nasal obstruction and dissatisfaction with the shape of his nose was referred to our outpatient clinic. From the Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea. Received December 8, 2013. Accepted for publication December 29, 2013. Address correspondence and reprint requests to Jae Min Hong, MD, Department of Otorhinolaryngology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752 Republic of Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000693

FIGURE 1. Plain radiographs of the lateral side of the neck. Plain radiographs of the lateral side of the neck showed emphysema on the right side of the upper neck (arrow).

The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014

Kim et al

hospitalized for bed rest. The patient was treated with broad spectrum of antibiotics (metronidazole 500 mg every 8 h, ceftriaxone 1 g every 12 h). On the third day after the hospitalization, pain was relieved and the subcutaneous crepitus disappeared on the fourth day. Follow-up CT was performed on the fifth day after the hospitalization. On follow-up CT scans, the subcutaneous emphysema and pneumomediastinum were markedly decreased (Fig. 3). He was discharged on the fifth day.

DISCUSSION Septorhinoplasty could cause numerous complications such as epistaxis, septal hematoma, orbital hemorrhage, enophthalmos, and necrotizing periorbital cellulitis.5–7 However, postoperative subcutaneous emphysema and pneumomediastinum are very rare complications after septorhinoplasty. There were only 2 reported cases in the English literature. Celebioglu et al1 reported a case of a 24-year-old male patient after septorhinoplasty under local anesthesia. Dubost et al4 also reported a case of a 26-year-old female patient after her fourth septorhinoplasty under general anesthesia. Different from the previously mentioned 2 patients, our patient showed a symptom on the fifth day after the surgery. However, the previously mentioned 2 patients showed symptoms immediately approximately 4 hours after the surgery. In our patient, the nasal packing was removed already before the symptom began. Therefore, air could enter through the right lateral osteotomy incisions, which produced a 1-way valve effect, allowing air to enter but not to escape. We suggest that subcutaneous emphysema and pneumomediastinum may be developed in this manner when the patient sneezes. The clinical features of subcutaneous emphysema are edema, sudden facial and cervical swelling, and crepitus on palpation. The signs of pneumomediastinum are dyspnea with a brassy voice, chest or back pain, and Hamman sign.8 It is really important to make a differential diagnosis of subcutaneous emphysema from other complications such as subcutaneous hematoma or angioedema. Subcutaneous emphysema always presents with a tactile crepitus on palpation. Computed tomography is the most reliable modality for the diagnosis of subcutaneous emphysema and pneumomediastinum. Although the presence of subcutaneous emphysema can be detected with plain radiograph, it is difficult to determine its extent in detail.9 For example, in our patient, plain radiograph did not show the precise extent and sufficient information of the emphysema.

FIGURE 2. Computed tomographic scans. On the fifth day after the surgery CT scans, air was observed in the right temporal space (A), masticator space (B), right submandibular space (C), and superior mediastinal space (D).

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FIGURE 3. Follow-up CT scans. On the fifth day after the hospitalization, subcutaneous emphysema and pneumomediastinum were markedly decreased (A-D).

In most cases, treatments of subcutaneous emphysema are simple bed rest and closed observation with administration of antibiotics. However, there have been reports of deaths after dental extraction because of severe complications, such as pneumothorax, cardiac tamponade, cardiac failure, and air ambolism.10 Although patients initially had no respiratory symptom at the onset of subcutaneous emphysema, gradual expansion of emphysema could develop severe pneumomediastinum or pneumothorax and other severe complications, leading to dyspnea. Therefore, close monitoring and serial CT are important to manage these unusual complications after septorhinoplasty.

CONCLUSIONS We report an unusual case of postoperative subcutaneous emphysema and pneumomediastinum after septorhinoplasty. We suggest that subcutaneous emphysema and pneumomediastinum may be developed because air entered through the right lateral osteotomy incisions, which produced a 1-way valve effect. Computed tomographic scan is the most reliable modality for the diagnosis of this complication, and close monitoring and serial CT are important to manage this complication.

REFERENCES 1. Celebioglu S, Keser A, Ortak T. An unusual complication of rhinoplasty: subcutaneous emphysema. Br J Plast Surg 1998;51:266–267 2. Durukan P, Salt O, Ozkan S, et al. Cervicofacial emphysema and pneumomediastinum after a high-speed air drill endodontic treatment procedure. Am J Emerg Med 2012;30:2095 3. De Luca G, Petteruti F, Tanga M, et al. Pneumomediastinum and subcutaneous emphysema unusual complications of blunt facial trauma. Indian J Surg 2011;73:380–381 4. Dubost J, Kalfon F, Roullit S, et al. Giant subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax following rhinoseptoplasty. Cah Anesthesiol 1986;34:161–162 5. Hunts JH, Patrinely JR, Stal S. Orbital hemorrhage during rhinoplasty. Ann Plast Surg 1996;37:618–623 6. Eloy JA, Jacobson AS, Elahi E, et al. Enophthalmos as a complication of rhinoplasty. Laryngoscope 2006;116:1035–1038 7. Moscona R, Ullmann Y, Peled I. Necrotizing periorbital cellulitis following septorhinoplasty. Aesthetic Plast Surg 1991;15:187–190 8. Hamman L. Spontaneous pneumothorax. Trans Am Clin Climatol Assoc 1914;30:273–289 9. Lillard RL, Allen RP. The extrapleural air sign in pneumomediastinum. Radiology 1965;85:1093–1098 10. Aragon SB, Dolwick MF, Buckley S. Pneumomediastinum and subcutaneous cervical emphysema during third molar extraction under general anesthesia. J Oral Maxillofac Surg 1986;44:141–144

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Cervical subcutaneous emphysema and pneumomediastinum after septorhinoplasty.

Cervical and facial subcutaneous emphysema is mainly caused by maxillofacial trauma or head and neck surgery. There are only 2 cases of subcutaneous e...
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