Diagnostic Radiology
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Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction 1
Carl M. Sandler, M.D., Herman I. Llbshltz, M.D.,2 and Gerald Marks, M.D. Pneumoperitoneum, pneumomediastinum, pneumopericardium and subcutaneous emphysema developed in a patient following simple dental extraction. Other causes of this unusual complication, such as pneumatosis cystoides intestinalis, insufflation of fallopian tubes, pulmonary-peritoneal fistula, postpartum knee-chest exer:cises, laparotomy, paracentesis and peritoneal dialysis should be considered when peritoneal signs are absent so that unnecessary laparotomy can be avoided. INDEX TERMS: Emphysema, subcutaneous. Pneumomediastinum • Pneumoperitoneum • Pneumopericardium • Teeth Radiology 115:539-540, June 1975
NEUMOPERITONEUM is usually a manifestation of a perforated viscus which demands immediate laparotomy. It is well known, however, that air may enter the peritoneal cavity through routes other than the gastrointestinal tract and therefore a more conservative approach may be indicated. Such cases are usually referred to as "idiopathic pneumoperitoneum" (10) and may be caused by pneumatosis cystoides intestinalis (2); insufflation of fallopian tubes (4); laparotomy, paracentesis, or peritoneal dialysis; postpartum knee-chest exercises (7); and pulmonary-peritoneal fistula (10). We wish to report a case in which pneumoperitoneum, accompanied by pneumomediastinum, pneumopericardium and subcutaneous emphysema developed following a simple dental extraction.
P
Fig. 1. PA radiograph of the chest showing massive pneumoperitoneum with pneumomediastinum and pneumopericardium (arrows). Subcutaneous emphysema is present in the neck bilaterally. large quantity of air which caused marked symptomatic improvement. The patient was given antibiotics and 70 % oxygen by mask and the vital signs remained stable. On the third hospital day, a repeat complete blood count was within normal limits. The patient continued to complain of shoulder and neck pain but this gradually diminished. Follow-up radiographs confirmed a decrease in the subcutaneous emphysema and pneumoperitoneum. The patient was discharged on the sixth hospital day.
CASE REPORT A 28-year-old woman had two right lower molar teeth extracted under intravenous anesthesia without the use of a high-speed air-turbine drill. Upon awakening from the anesthetic, she complained of vague abdominal discomfort and chest pain. She was given oxygen by mask and chlordiazepoxide hydrochlorlde.i' 10 mg orally. After returning home, she complained of increasing abdominal bloated ness and was advised to go to the hospital. There was no prior history of gastrointestinal or cardiovascular disease. Her temperature was 99.6°F, pulse 88 and regular, blood pressure 120/80, and respiration 24. Physical examination revealed swelling with crepitation around the neck and chest. There was generalized abdominal distension without rebound or point tenderness. The bowel sounds were slightly hypoactive. The remainder of the examination was within normal limits. The patient had a hemoglobin of 13.1 g and a white blood count of 11,600. Other laboratory studies were unremarkable. Radiographic examination disclosed extensive subcutaneous emphysema involving the neck and chest. Pneumomediastinum, pneumopericardium, and massive pneumoperitoneum were present. No pneumothorax was identified (Fig. 1). Abdominal paracentesis was performed with the release of a
DISCUSSION
Although most cases of subcutaneous emphysema and pneumomediastinum following oral surgery (6, 9, 11, 12) were associated with the use of high speed air-turbine drills (11), the phenomenon is not new. It was first noticed about 100 years ago when a musician began blowing a bugle right after a tooth extraction (13). The first report of this complication in the medical literature appeared in 1968 (5); all of the earlier studies were published in dental journals. We are unaware of any previous report in which pneumoperitoneum was a feature as well. A brief review of the anatomy of the neck contributes to an understanding of this unusual complication. The cervical fascia is divided into superficial and deep
1 From the Departments of Radiology (C. M. S., H. I. L.) and Surgery (G. M.), Thomas Jefferson University Hospital, Philadelphia, Pa. Accepted for publication in January 1975. 2 Present address: Department of Radiology, Duke University Medical Center, Durham, N. C. 27710. 3 Librium, Roche Laboratories, Nutley, N. J. 07110. shan
539
540
CARL
M. SANDLER AND OTHERS
layers. The deep layer in turn divides into the anterior, middle, and visceral layers. These fascial layers form the boundaries of potential spaces known as the fascial spaces of the neck. The submandibular space is located beneath the body of the mandible and is divided into three parts: the sublingual, submaxillary, and submental compartments. The sublingual space is in direct communication with the roots of the first, second and sometimes the third mandibular molar teeth (11). The submaxillary compartment communicates posteromedially with the retropharyngeal space and thus into the mediastinum. When air enters the fascial planes of the neck, subcutaneous emphysema may be produced. Macklin and Macklin (8) have described the passage of air from the mediastinum along the perivascular spaces and the esophaqus into the retroperitoneal space. From the retroperitoneum air may then rupture into the peritoneal cavity. This same route has been postulated recently by Aranda et al. (1) as the mechanism responsible for idiopathic pneumoperitoneum in a child with hyaline membrane disease. Donahue et al. (3) reported a similar case and confirmed this mechanism experimentally in rats. They felt, however, that pressures great enough to cause pneumoperitoneum would almost invariably first produce pneumothorax from alveolar rupture. This did not occur in our case. In this report, we have demonstrated an unusual cause for pneumoperitoneum accompanied by subcutaneous emphysema, pneumopericardium and pneumomediastinum. While pneumoperitoneum most often is a manifestation of a gastrointestinal perforation, other rare causes for this symptom should be considered when peritoneal signs are absent so that unnecessary laparotomy can be avoided.
REFERENCES 1.
Aranda JV, Stern L, Dunbar JS:
Pneumothorax with pneu-
June 1975
moperitoneum in a newborn infant. Am J Dis Child 123:163":166, Feb 1972 2. Ayres RW, Beeson CR, Scruggs JB: Idiopathic pneumoperitoneum. A review of the literature and report of one case. Am J Dig Dis 17:345-347, Oct 1950 3. Donahoe PK, Osmond JD III, Stewart DR, et al: Pneumoperitoneum secondary to pulmonary air leak. J Pediatr 81:797-800, Oct 1972 4. Freeman RK: Pneumoperitoneum from oral-genital insufflation (letter). Obstet GynecoI36:162-164, Jul1970 5. Hunt RB, Sahler 00: Mediastinal "emphysema produced by air turbine dental drills. JAMA 205: 101-102, 22 Jul 1968 6. Kleinman HZ: Subcutaneous and mediastinal emphysema after oral surgery. Report of a case. J Oral Surg 19:527, Nov 1961 7. Lozman H, Newman AJ: Spontaneous pneumoperitoneum occurring during postpartum exercises in the knee-chest position. Am J Obstet Gynec 72:903-905, Oct 1956 8. Macklin MT, Macklin CC: Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions. An interpretation of the clinical literature in the light of laboratory experiment. Medicine 23:281-358, Dec 1944 9. Marlette RH: Mediastinal emphysema following tooth extraction. Oral Surg 16:116-119, Jan 1963 10. McGlone FB, Vivion CG Jr, Meir L: Spontaneous pneumoperitoneum. Gastroenterology 51:393-398, Sep 1966 11. Meyerhoff WL, Nelson R, Fry WA: Mediastinal emphysema after oral surgery. J Oral Surg 31:477-479, Jun 1973 12. Noble WH: Mediastinal emphysema resulting from extraction of an impacted mandibular third molar. J Am Dent Assoc 84: 368-370, Feb 1972 13. Turnbull A: Remarkable coincidence in dental surgery (letter). Br Med J 1:1131, 5 May 1900
Herman I. Libshitz, M.D. Department of Radiology Duke University Medical Center Durham, N. C. 27710
•
Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction 1
Carl M. Sandler, M.D., Herman I. Llbshltz, M.D.,2 and Gerald Marks, M.D. Pneumoperitoneum, pneumomediastinum, pneumopericardium and subcutaneous emphysema developed in a patient following simple dental extraction. Other causes of this unusual complication, such as pneumatosis cystoides intestinalis, insufflation of fallopian tubes, pulmonary-peritoneal fistula, postpartum knee-chest exer:cises, laparotomy, paracentesis and peritoneal dialysis should be considered when peritoneal signs are absent so that unnecessary laparotomy can be avoided. INDEX TERMS: Emphysema, subcutaneous. Pneumomediastinum • Pneumoperitoneum • Pneumopericardium • Teeth Radiology 115:539-540, June 1975
NEUMOPERITONEUM is usually a manifestation of a perforated viscus which demands immediate laparotomy. It is well known, however, that air may enter the peritoneal cavity through routes other than the gastrointestinal tract and therefore a more conservative approach may be indicated. Such cases are usually referred to as "idiopathic pneumoperitoneum" (10) and may be caused by pneumatosis cystoides intestinalis (2); insufflation of fallopian tubes (4); laparotomy, paracentesis, or peritoneal dialysis; postpartum knee-chest exercises (7); and pulmonary-peritoneal fistula (10). We wish to report a case in which pneumoperitoneum, accompanied by pneumomediastinum, pneumopericardium and subcutaneous emphysema developed following a simple dental extraction.
P
Fig. 1. PA radiograph of the chest showing massive pneumoperitoneum with pneumomediastinum and pneumopericardium (arrows). Subcutaneous emphysema is present in the neck bilaterally. large quantity of air which caused marked symptomatic improvement. The patient was given antibiotics and 70 % oxygen by mask and the vital signs remained stable. On the third hospital day, a repeat complete blood count was within normal limits. The patient continued to complain of shoulder and neck pain but this gradually diminished. Follow-up radiographs confirmed a decrease in the subcutaneous emphysema and pneumoperitoneum. The patient was discharged on the sixth hospital day.
CASE REPORT A 28-year-old woman had two right lower molar teeth extracted under intravenous anesthesia without the use of a high-speed air-turbine drill. Upon awakening from the anesthetic, she complained of vague abdominal discomfort and chest pain. She was given oxygen by mask and chlordiazepoxide hydrochlorlde.i' 10 mg orally. After returning home, she complained of increasing abdominal bloated ness and was advised to go to the hospital. There was no prior history of gastrointestinal or cardiovascular disease. Her temperature was 99.6°F, pulse 88 and regular, blood pressure 120/80, and respiration 24. Physical examination revealed swelling with crepitation around the neck and chest. There was generalized abdominal distension without rebound or point tenderness. The bowel sounds were slightly hypoactive. The remainder of the examination was within normal limits. The patient had a hemoglobin of 13.1 g and a white blood count of 11,600. Other laboratory studies were unremarkable. Radiographic examination disclosed extensive subcutaneous emphysema involving the neck and chest. Pneumomediastinum, pneumopericardium, and massive pneumoperitoneum were present. No pneumothorax was identified (Fig. 1). Abdominal paracentesis was performed with the release of a
DISCUSSION
Although most cases of subcutaneous emphysema and pneumomediastinum following oral surgery (6, 9, 11, 12) were associated with the use of high speed air-turbine drills (11), the phenomenon is not new. It was first noticed about 100 years ago when a musician began blowing a bugle right after a tooth extraction (13). The first report of this complication in the medical literature appeared in 1968 (5); all of the earlier studies were published in dental journals. We are unaware of any previous report in which pneumoperitoneum was a feature as well. A brief review of the anatomy of the neck contributes to an understanding of this unusual complication. The cervical fascia is divided into superficial and deep
1 From the Departments of Radiology (C. M. S., H. I. L.) and Surgery (G. M.), Thomas Jefferson University Hospital, Philadelphia, Pa. Accepted for publication in January 1975. 2 Present address: Department of Radiology, Duke University Medical Center, Durham, N. C. 27710. 3 Librium, Roche Laboratories, Nutley, N. J. 07110. shan
539
540
CARL
M. SANDLER AND OTHERS
layers. The deep layer in turn divides into the anterior, middle, and visceral layers. These fascial layers form the boundaries of potential spaces known as the fascial spaces of the neck. The submandibular space is located beneath the body of the mandible and is divided into three parts: the sublingual, submaxillary, and submental compartments. The sublingual space is in direct communication with the roots of the first, second and sometimes the third mandibular molar teeth (11). The submaxillary compartment communicates posteromedially with the retropharyngeal space and thus into the mediastinum. When air enters the fascial planes of the neck, subcutaneous emphysema may be produced. Macklin and Macklin (8) have described the passage of air from the mediastinum along the perivascular spaces and the esophaqus into the retroperitoneal space. From the retroperitoneum air may then rupture into the peritoneal cavity. This same route has been postulated recently by Aranda et al. (1) as the mechanism responsible for idiopathic pneumoperitoneum in a child with hyaline membrane disease. Donahue et al. (3) reported a similar case and confirmed this mechanism experimentally in rats. They felt, however, that pressures great enough to cause pneumoperitoneum would almost invariably first produce pneumothorax from alveolar rupture. This did not occur in our case. In this report, we have demonstrated an unusual cause for pneumoperitoneum accompanied by subcutaneous emphysema, pneumopericardium and pneumomediastinum. While pneumoperitoneum most often is a manifestation of a gastrointestinal perforation, other rare causes for this symptom should be considered when peritoneal signs are absent so that unnecessary laparotomy can be avoided.
REFERENCES 1.
Aranda JV, Stern L, Dunbar JS:
Pneumothorax with pneu-
June 1975
moperitoneum in a newborn infant. Am J Dis Child 123:163":166, Feb 1972 2. Ayres RW, Beeson CR, Scruggs JB: Idiopathic pneumoperitoneum. A review of the literature and report of one case. Am J Dig Dis 17:345-347, Oct 1950 3. Donahoe PK, Osmond JD III, Stewart DR, et al: Pneumoperitoneum secondary to pulmonary air leak. J Pediatr 81:797-800, Oct 1972 4. Freeman RK: Pneumoperitoneum from oral-genital insufflation (letter). Obstet GynecoI36:162-164, Jul1970 5. Hunt RB, Sahler 00: Mediastinal "emphysema produced by air turbine dental drills. JAMA 205: 101-102, 22 Jul 1968 6. Kleinman HZ: Subcutaneous and mediastinal emphysema after oral surgery. Report of a case. J Oral Surg 19:527, Nov 1961 7. Lozman H, Newman AJ: Spontaneous pneumoperitoneum occurring during postpartum exercises in the knee-chest position. Am J Obstet Gynec 72:903-905, Oct 1956 8. Macklin MT, Macklin CC: Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions. An interpretation of the clinical literature in the light of laboratory experiment. Medicine 23:281-358, Dec 1944 9. Marlette RH: Mediastinal emphysema following tooth extraction. Oral Surg 16:116-119, Jan 1963 10. McGlone FB, Vivion CG Jr, Meir L: Spontaneous pneumoperitoneum. Gastroenterology 51:393-398, Sep 1966 11. Meyerhoff WL, Nelson R, Fry WA: Mediastinal emphysema after oral surgery. J Oral Surg 31:477-479, Jun 1973 12. Noble WH: Mediastinal emphysema resulting from extraction of an impacted mandibular third molar. J Am Dent Assoc 84: 368-370, Feb 1972 13. Turnbull A: Remarkable coincidence in dental surgery (letter). Br Med J 1:1131, 5 May 1900
Herman I. Libshitz, M.D. Department of Radiology Duke University Medical Center Durham, N. C. 27710
