Iatrogenic pneumomediastinum after endodontic therapy 0. Nahlieli. ORAL
AND
DMD, and A. Neder, DMD, Ashkelon, Israel MAXILLOFACIAL
SURGERY
UNIT,
BARZILAI
MEDICAL
CENTER
An unusual case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal treatment is described in a 30-year-old man. A thorough search of the available literature failed to reveal similar cases. A review of the literature. including pathogenesis, clinical and radiographic features, and management of this condition, is presented. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:618-9)
I
atrogenic pneumomediastinum after endodontic therapy is an uncommon event usually occurring after trauma, surgical, or anesthesiologic measures. However, it seemsto be far more common in practice than the paucity of reported cases indicates. We present an unusual case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal therapy. CASE REPORT
A 30-year-old man was referred from a dental clinic to the hospital emergency room. The patient had acute pulpitis of the lower right third molar, which had been treated by extirpation followed by irrigation with 3% hydrogen peroxide solution. Soon after the irrigation, subcutaneous emphysema was observed and immediately diagnosed. Shortly thereafter, the patient complained of shortness of breath and pressure in the chest. On admission the patient appeared in generally good condition; pulse, blood pressure, electrocardiogram, and heart and lung sounds showed no abnormalities. Radiography of chest revealed air in the mediastinum (Figs. 1 and 2). Treatment consisted of 2.0 gm/day of ampicillin given orally for 10 days. The patient was discharged 4 days later with improved physical condition. The emphysemasubsidedafter 2 weeks. The lower right molar tooth was extracted 15 days later because of alveolar abscess,at which time a follow-up examination showed no abnormalities (Fig. 3). DISCUSSION
Air may enter the tissues by way of injuries of the respiratory and alimentary tracts. The mechanism governing the entrance of air are trauma and surgical 7/S/27190 616
Fig. 1. X-ray film of neck and chest, on admission, shows lines of air bilaterally in neck and pneumomediastinum.
or anesthesiologicmeasures;spontaneousentry is also possible. Infections with gas-forming bacteria are very rare.’ Iatrogenic mediastinal emphysemamay result from
Iatrogenic pneumomediastinum
Volume 71 Number 5
619
case of infraorbital emphysema caused by oxygen liberated from hydrogen peroxide during irrigation of a root canal was reported by Bhat et a1.12We join Horowitz et a1.8in the opinion that it is possible that mediastinal emphysema after a complication of surgical extraction is not new; thus many subclinical cases remain undiagnosed. Therefore in suspected cases it is recommended to take chest x-ray films. SUMMARY
Fig.
2. Chest x-ray film on admission.
A unique case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal therapy is reported. The condition did not appear to be caused by the surgical procedure, because no dental equipment powered by highly compressed air was used. However, the hydrogen peroxide lavage may have generated a sufficient quantity of gas or tension that entered the soft tissue directly by being forced down the dental root canal. A review of the literature including the pathogenesis, clinical and radiographic features, and management of such conditions is given. REFERENCES
3. Panoramic x-ray film of involved tooth (right lower third molar) before extraction. Fig.
use of dental equipment powered by highly compressedair. The high-speed dental handpiece (air turbine handpiece) and the air and water dental syringe (Cavi-Jets, O.M.S., Bologna, Italy) are the instruments most commonly implicated in the reported cases.2-8Jet ventilation anesthesia,’ pulmonary barotrauma caused by a faulty expiratory valve,‘O and oxygen leak through an endotracheal tube’ ’ are also reported as possible causes of pneumomediastinum. Such events may result in a typical clinical complex lasting a few days and consisting of pain, dyspnea, fever, and leukocytosis. Becausethere is a potential for mediastinitis, antibiotic therapy is recommended.3 In our case pneumomediastinum did not appear to be caused by the surgical procedure, becauseno dental instrument powered by highly compressedair was used. The hydrogen peroxide irrigation may have rapidly undergone effervescence,liberating oxygen in presence of blood and tissue proteins. The produced gases may have entered the soft tissues directly by being forced down and then may have passedby way of fascial planes to enter deeper structures and the mediastinum. A thorough search of the available literature failed to reveal similar cases; however, a inappropriate
1. Falomo 00. Surgical emphysema following root canal therapy. ORAL SURCORAL MED ORAL PATHOL1984;58:101-2. 2. Dezeros G. Mougel JP, Maloisel MM, Simon A. Subcutaneous emphysema, pneumomediastinum and dental extraction. Ann Fr Anesth Reanim 1984;3:140-2. 3. Ikard RW. Pneumomediastinumafter dental extraction. South Med J 1984;77:801-2. 4. Wilson GA, Galle S, Greene C. Subcutaneousemphysema after extraction of maxillary teeth: a report of a case.J Am Dent Assoc 1983;106:836-7. 5. Ertl L, Prager R. Facial and mediastinal emphysema after tooth extraction. Osterr Z Stomatol 1983;80:340-2. 6. Kern C, Tassonyi E. Pneumomediastinum: complications due to the use of a jet of compressedair. Can J Anaesth 1989;36: 78-80. I. Finlayson RS, Stevens FD. Subcutaneous facial emphysema
secondaryto useof the Cavi-Jet. J Periodontol 1988;59:315-7. 8. Horowitz I, Hirshberg A, Freedman A. Pneumomediastinum
and subcutaneousemphysema following surgical extraction of mandibular third molars: three casereports. ORAL SURG ORAL MED ORAL PATHOL
1987;63:25-8.
9. Wetmore SJ, Key JM, Suen JY. Complications of laser sur-
geryforlaryngealpapiIlomatosis.Laryng~co~1985;95:798-801. 10. Aragon SB, Dolwick MF, Buckley S. Pneumomediastinum and subcutaneouscervical emphysema during third molar extraction under general anesthesia. J Oral Maxillofac Surg 1986;44:141-4. 11. WasserbergerJ, Ordog GJ, Turner AF, et al. Iatrogenic pulmonary overpressureaccident. Ann Emerg Med 1986;15:847-51. 12. Bhat KS. Tissue emphysema caused by hydrogen peroxide. ORAL SURG ORAL
MED ORAL PATHOL
Reprint requests to:
0. Nahlieli, DMD Oral and Maxillofacial Surgery Unit Barzilai Medical Center Ashkelon 78306, Israel
1974;38:304-7.
AND
DMD, and A. Neder, DMD, Ashkelon, Israel MAXILLOFACIAL
SURGERY
UNIT,
BARZILAI
MEDICAL
CENTER
An unusual case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal treatment is described in a 30-year-old man. A thorough search of the available literature failed to reveal similar cases. A review of the literature. including pathogenesis, clinical and radiographic features, and management of this condition, is presented. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:618-9)
I
atrogenic pneumomediastinum after endodontic therapy is an uncommon event usually occurring after trauma, surgical, or anesthesiologic measures. However, it seemsto be far more common in practice than the paucity of reported cases indicates. We present an unusual case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal therapy. CASE REPORT
A 30-year-old man was referred from a dental clinic to the hospital emergency room. The patient had acute pulpitis of the lower right third molar, which had been treated by extirpation followed by irrigation with 3% hydrogen peroxide solution. Soon after the irrigation, subcutaneous emphysema was observed and immediately diagnosed. Shortly thereafter, the patient complained of shortness of breath and pressure in the chest. On admission the patient appeared in generally good condition; pulse, blood pressure, electrocardiogram, and heart and lung sounds showed no abnormalities. Radiography of chest revealed air in the mediastinum (Figs. 1 and 2). Treatment consisted of 2.0 gm/day of ampicillin given orally for 10 days. The patient was discharged 4 days later with improved physical condition. The emphysemasubsidedafter 2 weeks. The lower right molar tooth was extracted 15 days later because of alveolar abscess,at which time a follow-up examination showed no abnormalities (Fig. 3). DISCUSSION
Air may enter the tissues by way of injuries of the respiratory and alimentary tracts. The mechanism governing the entrance of air are trauma and surgical 7/S/27190 616
Fig. 1. X-ray film of neck and chest, on admission, shows lines of air bilaterally in neck and pneumomediastinum.
or anesthesiologicmeasures;spontaneousentry is also possible. Infections with gas-forming bacteria are very rare.’ Iatrogenic mediastinal emphysemamay result from
Iatrogenic pneumomediastinum
Volume 71 Number 5
619
case of infraorbital emphysema caused by oxygen liberated from hydrogen peroxide during irrigation of a root canal was reported by Bhat et a1.12We join Horowitz et a1.8in the opinion that it is possible that mediastinal emphysema after a complication of surgical extraction is not new; thus many subclinical cases remain undiagnosed. Therefore in suspected cases it is recommended to take chest x-ray films. SUMMARY
Fig.
2. Chest x-ray film on admission.
A unique case of pneumomediastinum caused by subcutaneous emphysema occurring after the use of hydrogen peroxide solution during root canal therapy is reported. The condition did not appear to be caused by the surgical procedure, because no dental equipment powered by highly compressed air was used. However, the hydrogen peroxide lavage may have generated a sufficient quantity of gas or tension that entered the soft tissue directly by being forced down the dental root canal. A review of the literature including the pathogenesis, clinical and radiographic features, and management of such conditions is given. REFERENCES
3. Panoramic x-ray film of involved tooth (right lower third molar) before extraction. Fig.
use of dental equipment powered by highly compressedair. The high-speed dental handpiece (air turbine handpiece) and the air and water dental syringe (Cavi-Jets, O.M.S., Bologna, Italy) are the instruments most commonly implicated in the reported cases.2-8Jet ventilation anesthesia,’ pulmonary barotrauma caused by a faulty expiratory valve,‘O and oxygen leak through an endotracheal tube’ ’ are also reported as possible causes of pneumomediastinum. Such events may result in a typical clinical complex lasting a few days and consisting of pain, dyspnea, fever, and leukocytosis. Becausethere is a potential for mediastinitis, antibiotic therapy is recommended.3 In our case pneumomediastinum did not appear to be caused by the surgical procedure, becauseno dental instrument powered by highly compressedair was used. The hydrogen peroxide irrigation may have rapidly undergone effervescence,liberating oxygen in presence of blood and tissue proteins. The produced gases may have entered the soft tissues directly by being forced down and then may have passedby way of fascial planes to enter deeper structures and the mediastinum. A thorough search of the available literature failed to reveal similar cases; however, a inappropriate
1. Falomo 00. Surgical emphysema following root canal therapy. ORAL SURCORAL MED ORAL PATHOL1984;58:101-2. 2. Dezeros G. Mougel JP, Maloisel MM, Simon A. Subcutaneous emphysema, pneumomediastinum and dental extraction. Ann Fr Anesth Reanim 1984;3:140-2. 3. Ikard RW. Pneumomediastinumafter dental extraction. South Med J 1984;77:801-2. 4. Wilson GA, Galle S, Greene C. Subcutaneousemphysema after extraction of maxillary teeth: a report of a case.J Am Dent Assoc 1983;106:836-7. 5. Ertl L, Prager R. Facial and mediastinal emphysema after tooth extraction. Osterr Z Stomatol 1983;80:340-2. 6. Kern C, Tassonyi E. Pneumomediastinum: complications due to the use of a jet of compressedair. Can J Anaesth 1989;36: 78-80. I. Finlayson RS, Stevens FD. Subcutaneous facial emphysema
secondaryto useof the Cavi-Jet. J Periodontol 1988;59:315-7. 8. Horowitz I, Hirshberg A, Freedman A. Pneumomediastinum
and subcutaneousemphysema following surgical extraction of mandibular third molars: three casereports. ORAL SURG ORAL MED ORAL PATHOL
1987;63:25-8.
9. Wetmore SJ, Key JM, Suen JY. Complications of laser sur-
geryforlaryngealpapiIlomatosis.Laryng~co~1985;95:798-801. 10. Aragon SB, Dolwick MF, Buckley S. Pneumomediastinum and subcutaneouscervical emphysema during third molar extraction under general anesthesia. J Oral Maxillofac Surg 1986;44:141-4. 11. WasserbergerJ, Ordog GJ, Turner AF, et al. Iatrogenic pulmonary overpressureaccident. Ann Emerg Med 1986;15:847-51. 12. Bhat KS. Tissue emphysema caused by hydrogen peroxide. ORAL SURG ORAL
MED ORAL PATHOL
Reprint requests to:
0. Nahlieli, DMD Oral and Maxillofacial Surgery Unit Barzilai Medical Center Ashkelon 78306, Israel
1974;38:304-7.
