American Journal of Emergency Medicine xxx (2014) xxx–xxx

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Case Report

Occurrence of pneumomediastinum due to dental procedures Abstract The occurrence of pneumomediastinum and massive subcutaneous emphysema due to dental procedures is quite rare. We present a case of pneumomediastinum and massive subcutaneous emphysema that occurred during third molar tooth extraction with air-turbine handpiece. A 33-year-old woman with acute cervical and facial swelling was referred to the emergency department by the oral surgeon. After administering the injection (lidocaine HCl–epinephrine and articaine HCl) for 3 times, molar tooth extraction was started with air-turbine handpiece. The procedure was stopped as the patient complained of a swelling; medications for angioedema were then administered immediately. Significant bilateral cervical and facial swelling and crepitus by palpation were detected during physical examination. Her chest and neck radiographs showed widespread subcutaneous emphysema in both cervical and facial areas. Thoracic and cervical computed tomographic scan showed air in the subcutaneous and cervical spaces extending to the mediastinum. Intravenous ampicillin-sulbactam therapy was devised to eliminate potential spread of infection. The patient underwent a thoracic surgery and was hospitalized for oxygen therapy and observation. The patient was discharged 3 days after admission without any complications. The control radiographs of the patient in day 6 showed a nearly complete regression. Complications of dental procedures, which are usually benign and self-limited, rarely can cause life-threatening conditions such as tension pneumothorax, mediastinitis, and air embolism. The differential diagnosis of emphysematous complaints should include allergic reactions, hematoma, cellulitis, and angioedema. The occurrence of pneumomediastinum and massive subcutaneous emphysema due to dental procedures is so rare. After the identification of the first case in 1900, only a few cases have been reported per year [1-6]. These complications, which are usually benign and self-limited, rarely can cause life-threatening conditions such as tension pneumothorax, mediastinitis, and air embolism. The use of high-speed airturbine handpiece has been reported as the most common cause of these complications. However, molar tooth extraction (especially third) has been documented as the most common surgical dental procedure [4,5]. In this work, we present a case of pneumomediastinum and massive subcutaneous emphysema that occurred during third molar tooth extraction with air-turbine handpiece. A 33-year-old woman with acute cervical and facial swelling was referred to the emergency department (ED) by the oral surgeon. In her past medical history, she had mild asthma and made a complaint on a molar tooth infection a week earlier. For that reason, she used an antibiotic without any advice from a physician and the infection lessened. The right lower third molar tooth extraction was determined when she consulted the oral surgeon. After administering the

injection (lidocaine HCl–epinephrine and articaine HCl) for 3 times, molar tooth extraction was started with air-turbine handpiece. The procedure was stopped as the patient complained of a swelling; medications for angioedema were then administered immediately. The patient was referred to the ED within an hour. The vital signs shown by the patient in ED were: a heart rate of 60per minute; blood pressure of 160/100 mm Hg; respiratory rate of 17 per minute; temperature of 36.4°C; and an oxygen saturation of 94%. Significant bilateral cervical and facial swelling and crepitus by palpation were detected during physical examination. There was no significant wound or laceration detected from oral examination. Her chest and neck radiographs showed widespread subcutaneous emphysema in both cervical and facial areas (Fig. 1). Then, computed tomography (CT) was performed; thoracic and cervical CT scan showed air in the subcutaneous and cervical spaces extending to the mediastinum (Figs. 2-3). Intravenous ampicillin-sulbactam therapy was devised to eliminate potential spread of infection. The patient underwent a thoracic surgery and was hospitalized for oxygen therapy and observation. The patient was discharged 3 days after admission without any complications. The control radiographs of the patient in day 6 showed a nearly complete regression (Fig. 1). Pneumomediastinum and massive subcutaneous emphysema are usually caused by traumatic injury, head-neck surgery, mechanical ventilation or invasive procedures (such as bronchoscopy). In addition, they are rarely presented during dental procedures. When reviewing the case reports, third molar tooth extraction with airturbine handpiece was observed as the most frequent cause [3,4]. Swelling, dysphagia, chest pain, and crepitus are common signs and symptoms of subcutaneous emphysema. These symptoms may occur immediately, within few hours or days [3,5]. The patient only described a swelling found during the procedure. Differential diagnosis of emphysematous complaints should be made from allergic reactions, hematoma, cellulitis, angioedema, and myocardial ischemia. Crepitus, a pathognomonic finding, separates emphysema from the other diagnoses [7]. Fascial structure of the neck is quite complex and includes the cervical fascias with potential spaces. These spaces are not real spaces; they contain small amounts of loose connective tissues. During dental procedures, firstly, the compressed air enters from the tooth roots to the submandibular space. It dissects through the cervical fascial planes and gradually extends between the spaces. Secondly, after access to lateral pharyngeal space and retropharyngeal space, spreading of air to the mediastinum and pericardium becomes easier. Therefore, these spaces are commonly potential pathways for the spread of any pathology as infection, abscess, or compressed air [4,8,9]. Cervical fascias are divided into deep and superficial fascias. Superficial fascias completely surround the neck (under the skin),

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Please cite this article as: Aslaner MA, et al, Occurrence of pneumomediastinum due to dental procedures, Am J Emerg Med (2014), http://dx. doi.org/10.1016/j.ajem.2014.05.055

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M.A. Aslaner et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Fig. 1. The patient’s chest and neck radiographs showed widespread subcutaneous emphysema in both cervical and facial areas.

whereas deep fascias create important cervical compartments and build anatomical walls against the spread of infections [10]. When considering neck spaces between the deep fascias, submandibular space extends the mandible to the hyoid bone under the tongue. This space is usually related to molar root infections. Submandibular space communicates directly with sublingual and submental spaces. The spread of oral infections to these spaces is known as Ludwig’s angina. This progressive condition causes swelling at the base of the mouth, dysphagia, and respiratory distress. Submandibular space continues with lateral pharyngeal and retropharyngeal spaces [10]. The retropharyngeal space, which appears in the posterior of the pharynx, extends from the skull base into the mediastinum, and this potential space is the most common cause of the spread of

Fig. 2. Oblique cut through the neck and airway. LPS, lateral pharyngeal space; RPS, retropharyngeal space; SMS, submandibular space; SMeS, submental space.

infections to the mediastinum; compressed air leading to the pneumomediastinum mostly follows the same paths [3]. Prevertebral space, found in the anterior part of the vertebral column, extends from the base of the skull to the coccyx. Danger space is located between the retropharyngeal space (anteriorly), and the prevertebral space (posteriorly). This space extends from the skull base to the diaphragm, and causes potential spread of oral infections to the mediastinum [10]. Administration of antibiotics is necessary for patients with pneumomediastinum and/or subcutaneous emphysema, especially if there is an infected teeth or underlying disease such as asthma. When large amounts of contaminated air and/or water gain access to the soft tissue during dental procedure, the risk of developing infections may increase easily. The possible microorganisms, such as Legionella and Pseudomonas, are found in dental compressed air. Therefore, physicians should treat these patients with antibiotics, paying close attention particularly to the presence of underlying diseases or dental infections [1,2,9,10]. Most of the patients who develop pneumomediastinum and massive subcutaneous emphysema after dental procedure show local symptoms, benign and self-limited in clinics. In worse cases, serious results of emphysematous complications include tracheostomy, thoracic drainage, mediastinitis, and air embolism [2,4,5,11,12]. Most cases of subcutaneous emphysema are resolved after 3 to 5 days; patients completely recover after 7 to 10 days. After a dental or surgical procedure, the patient should be enlightened on postoperative instructions, detailing the avoidance of increasing intraoral pressure by blowing the nose severely, vomiting, playing musical instruments, and avoidance of air travel. Complications of dental procedures, which are usually benign and self-limited, rarely can cause life-threatening conditions such as tension pneumothorax, mediastinitis, and air embolism. Differential diagnosis of emphysematous complaints should be made from allergic reactions, hematoma, cellulitis, and angioedema. When the differential diagnosis is difficult, the best option is to treat for anaphylactic reactions until a definitive diagnosis is achieved [2].

Please cite this article as: Aslaner MA, et al, Occurrence of pneumomediastinum due to dental procedures, Am J Emerg Med (2014), http://dx. doi.org/10.1016/j.ajem.2014.05.055

M.A. Aslaner et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

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Fig. 3. The patient’s chest and cervical CT scan showed air in the subcutaneous and cervical spaces extending to the mediastinum.

Mehmet Ali Aslaner, MD ⁎ Gül Nihal Kasap, MD Cihat Demir, MD Meltem Akkaş, MD Nalan M. Aksu, MD Department of Emergency Medicine, Hacettepe University, Medical School, Ankara, Turkey ⁎Corresponding author. Hacettepe University Faculty of Medicine Emergency Medicine Sıhhıye, Ankara, Turkey Email address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2014.05.055

References [1] Ali A, Cunliffe DR, Watt-Smith SR. Surgical emphysema and pneumomediastinum complicating dental extraction. Br Dent J 2000;188(11):589–90. [2] An GK, Zats B, Kunin M. Orbital, Mediastinal, and Cervicofacial Subcutaneous Emphysema after Endodontic Retreatment of a Mandibular Premolar: A Case Report. Journal of Endodontics 2014;40(6):880–3.

[3] Yang SC, Chiu TH, Lin TJ, et al. Subcutaneous emphysema and pneumomediastinum secondary to dental extraction: a case report and literature review. Kaohsiung J Med Sci 2006;22(12):641–5. [4] McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: a literature review. J Oral Maxillofac Surg 2009;67(6):1265–8. [5] Kim Y, Kim MR, Kim SJ. Iatrogenic pneumomediastinum with extensive subcutaneous emphysema after endodontic treatment: report of 2 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(2):e114–9. [6] Mitsunaga S, Iwai T, Aoki N, et al. Cervicofacial subcutaneous and mediastinal emphysema caused by air cooling spray of dental laser. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115(6):e13–6. [7] Mishra L, Patnaik S, Patro S, et al. Iatrogenic subcutaneous emphysema of endodontic origin: case report with literature review. J Clin Diagn Res 2014;8(1):279–81. [8] Kost M. Thoracic complications associated with utilization of the air turbine dental drill. AANA J 1996;64(3):288–92. [9] Dongel I, Bayram M, Uysal IO, et al. Subcutaneous emphysema and pneumomediastinum complicating a dental procedure. Ulus Travma Acil Cerrahi Derg 2012;18(4):361–3. [10] Bilecenoglu B, Onul M, Altay OT, et al. Cervicofacial emphysema after dental treatment with emphasis on the anatomy of the cervical fascia. J Craniofac Surg 2012;23(6):e544–8. [11] Wright KJ, Derkson GD, Riding KH. Tissue-space emphysema, tissue necrosis, and infection following use of compressed air during pulp therapy: case report. Pediatr Dent 1991;13(2):110–3. [12] Sekine J, Irie A, Dotsu H, et al. Bilateral pneumothorax with extensive subcutaneous emphysema manifested during third molar surgery: a case report. Int J Oral Maxillofac Surg 2000;29(5):355–7.

Please cite this article as: Aslaner MA, et al, Occurrence of pneumomediastinum due to dental procedures, Am J Emerg Med (2014), http://dx. doi.org/10.1016/j.ajem.2014.05.055

Occurrence of pneumomediastinum due to dental procedures.

The occurrence of pneumomediastinum and massive subcutaneous emphysema due to dental procedures is quite rare. We present a case of pneumomediastinum ...
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