Subcutaneous emphysema after tonsillectomy: case report

Abstracts

JUSTIFICATIVA E OBJETIVOS: A amigdalectomia é considerada um procedimento relativamente seguro. O objetivo deste relato foi mostrar uma complicação rara desta cirurgia, o enfisema subcutâneo. RELATO DO CASO: Paciente do sexo masculino, 25 anos, com amigdalite recorrente e hipertrofia de cornetos. Foi submetido a amigdalectomia e turbinectomia sob anestesia geral com intubação orotraqueal. A operação transcorreu sem intercorrências. Na sala de recuperação pós-anestésica (SRPA) o paciente agitou-se, apresentando grande esforço físico. Quatro horas após a cirurgia, notou-se edema crepitante e depressível no pescoço e na região parotídea esquerda, característico de enfisema subcutâneo. A tomografia computadorizada mostrou a existência de ar nas regiões malar e cervical (principalmente à esquerda), atingindo até o mediastino superior. Não houve obstrução das vias aéreas e o estado geral do paciente permaneceu estável. Teve alta hospitalar no dia seguinte e foi acompanhado no ambulatório. O enfisema regrediu totalmente após 10 dias. CONCLUSÕES: O enfisema subcutâneo é uma complicação rara da amigdalectomia, ocorrendo quase sempre após dissecções profundas da mucosa faríngea, quando se cria interface porosa que proporciona a entrada do ar. O aumento da pressão nas vias aéreas superiores pode contribuir para o problema.

CIRURGIA; COMPLICAÇÕES

CLINICAL REPORT

Subcutaneous emphysema after tonsillectomy. Case report^*

Enfisema subcutáneo después de amigdalectomia. Relato del caso

Walter Luiz Ferreira Lima, TSA, M.D.^I; Nivaldo Simões Correa, TSA, M.D.^I; José Luiz de Campos, M.D.^II; Paulo Moraes Navarro, M.D.^II; Luciano de Oliveira Correia, M.D.^III

^ICo-Responsável pelo CET/SBA do Hospital Vera Cruz

^IIAnestesiologista do Hospital Vera Cruz

^IIIME₂ do CET/SBA do Hospital Vera Cruz

^{Correspondence}

SUMMARY

BACKGROUND AND OBJECTIVES: Tonsillectomy is considered a relatively safe procedure. This report aimed at describing an uncommon complication of this surgical procedure: subcutaneous emphysema.

CASE REPORT: Male patient, 25 years old, admitted for recurrent tonsillitis and hypertrophic nasal turbinates. Tonsillectomy and nasal cauterization were performed under general anesthesia with tracheal intubation. Surgery was uneventful. At post-anesthetic recovery unit (PACU), patient was agitated and performing major physical effort. Four hours after surgery, gross and crepitus swelling of neck and left parotid region, typical of subcutaneous emphysema, was noted. CT scan has revealed free air in the malar and cervical regions (especially to the left), reaching upper mediastinum. There was no airway obstruction and his general condition was stable. Patient was discharged one day after and was followed on ambulatory basis. Emphysema was no longer clinically evident 10 days after.

CONCLUSIONS: Subcutaneous emphysema is an uncommon complication of tonsillectomy, appearing almost ever after deeper dissections of the pharyngeal mucosa, when a porous surface is created, thus providing a route for the entry of air. Increased upper airway pressure may contribute to this injury.

Key Words: COMPLICATIONS: subcutaneous emphysema; SURGERY: tonsillectomy

RESUMEN

JUSTIFICATIVA Y OBJETIVOS: La amigdalectomia se considera como un procedimiento relativamente seguro. El objetivo de este relato fue mostrar una complicación rara de esta cirugía, el enfisema subcutáneo.

RELATO DEL CASO: Paciente del sexo masculino, 25 años, con amigdalitis recurrente e hipertrofia de cornetes. Fue sometido a amigdalectomia y turbinectomia bajo anestesia general con intubación orotraqueal. La operación transcurrió sin intercurrencias. En la sala de recuperación pos-anestésica (SRPA) el paciente se agitó, presentando grande esfuerzo físico. Cuatro horas después de la cirugía, se notó un edema crepitante y depresible en el cuello y en la región parotídea izquierda, característico de enfisema subcutáneo. La tomografía computadorizada mostró la existencia de aire en las regiones malar y cervical (principalmente a la izquierda), alcanzando hasta el mediastino superior. No hubo obstrucción de las vías aéreas y el estado general del paciente permaneció estable. Tuvo alta hospitalario en el día siguiente y fue acompañado en el ambulatorio. El enfisema retrocedió totalmente después de 10 días.

CONCLUSIONES: El enfisema subcutáneo es una complicación rara de la amigdalectomia, ocurriendo casi siempre después de disecciones profundas de la mucosa faríngea, cuando se crea interface porosa que proporciona la entrada del aire. El aumento de la presión en las vías aéreas superiores puede contribuir para el problema.

INTRODUCTION

Tonsillectomy is one of the most common major surgical procedures highly prevalent in the pediatric population ¹. Although being a relatively safe procedure, some tonsillectomy complications have been described ^2-4, especially hemorrhage, in addition to others such as pain, fever, vomiting, dehydration, uvula edema, dental trauma, local infection, atlanto-axial subluxation, immune disorders, loss of vision and hypertensive crisis ^2,4,5. This report aimed at describing a case of post-tonsillectomy subcutaneous emphysema.

CASE REPORT

Male patient, 25 years old, 70 kg, physical status ASA II, with recurrent tonsillitis, right peri-tonsillar abscess and inferior turbinates hypertrophy, who was submitted to tonsillectomy and nasal cauterization.

During preoperative evaluation, patient referred being under regular use of haloperidol to treat behavioral disorders mainly characterized by agitation. Physical evaluation was normal, good general state, relaxed, Mallampati II, in addition to normal laboratory tests. Patient was duly informed about the anesthetic-surgical procedure and was premedicated with oral midazolam (15 mg) 40 minutes before surgery, with satisfactory results.

Monitoring consisted of pulse oximetry, cardioscopy and noninvasive blood pressure. After left arm venoclysis, anesthesia was induced with fentanyl (250 µg), droperidol (5 mg), cisatracurium (14 mg), propofol (200 mg) and 5% lidocaine (100 mg). Laryngoscopy and tracheal intubation with 7.5 endotracheal tube (with cuff) was uneventful. Anesthesia was maintained with oxygen, nitrous oxide and sevoflurane.

Patient was ventilated with a positive pressure ventilator, pressure cycled (25 cmH₂O) with 600 mL tidal volume. Surgery lasted 40 minutes with minor bleeding and without intercurrences. Patient was extubated in superficial anesthetic plane and a nº 3 Guedel airway was inserted in the oropharynx for oxygen therapy (3 L.min^-1). Postoperative positive pressure ventilation was not needed.

At emergence, patient presented severe agitation, with major physical effort and had to be refrained to bed. Patient was discharged from PACU approximately one hour after this event. Four hours after surgery, patient presented gross and crepitus swelling of neck and left parotid region extending to left lateral cervical region. Patient was in good general state, eupneic, conscious and with stable vital signs, only complaining of tonsillar lodge pain.

Oral cavity evaluation and pulmonary auscultation were normal. Chest X-rays were normal and cervical CT scan revealed malar and cervical subcutaneous emphysema, especially to the left, in addition to air image dissecting cervical fascia and extending to upper mediastinum (Figure 1). There was also interruption of the air column in the left tonsillar lodge.

Brazilian Journal of Anesthesiology, 2005; 55: 4: 441-444

Subcutaneous emphysema after tonsillectomy. Case report

Walter Luiz Ferreira Lima; Nivaldo Simões Correa; José Luiz de Campos;

Paulo Moraes Navarro; Luciano de Oliveira Correia

Patient was observed for the next 24 hours, fasting, and under prophylactic antibiotics. No cardiopulmonary changes were observed during this period and subcutaneous emphysema has progressively resolved, however incompletely. Ambulatory follow up was indicated after hospital discharge. Total resolution was seen 10 days after surgery.

DISCUSSION

Post-tonsillectomy subcutaneous emphysema is described in the medical literature, sometimes associated to pneumomediastinum ^6-8, pneumothorax ^3,6 and pneumoperitoneum, although being an uncommon complication of this surgery ^3,9-11.

Traumatic intubation, local anesthetic infiltrations and deep tonsillar lodge dissection break pharyngeal mucosa integrity and may create a porous surface which helps the entry of air ^3,6. Increased pharyngeal pressure caused by situations such as coughing, vomiting, physical effort, ventilation under excessive positive pressure, post-extubation manual ventilation and anesthetic circuit defects are decisive for the development of emphysema ^3,6.

When the air enters the mucosa, it goes through upper pharyngeal constrictor muscle and easily dissects cervicofascial plans occupying parapharyngeal spaces. The anatomic connection between parapharyngeal and retropharyngeal spaces may promote upper airway obstruction ^6,8,12. This is especially dangerous in young children, who have very fragile tracheal rings and may require emergency tracheostomy ⁹.

When large volumes of air progressively enter, there is the possibility of pneumomediastinum and even cardiac tamponade ¹¹. Dyspnea, dysfagia, chest pain, cyanosis and skin crepitation synchronized with cardiac systole (Hamman's sign) indicate pneumomediastinum ⁹.

Pneumothorax and pneumoperitoneum caused by air entry in the abdominal cavity via diaphragm orifices ^1,3 may limit respiratory function and worsen symptoms.

Crepitation and depression at palpation, in addition to radiological findings, confirm subcutaneous emphysema, and CT scan is the most recommended additional test ³.

The evolution of subcutaneous emphysema secondary to tonsillectomy is usually benign and self-limited ³. Treatment is conservative because, in general, process is spontaneously resolved ^3,9. Strict observation of cardiopulmonary function and progression of emphysema is critical ³. Attitudes which may worsen the problem should be avoided, such as activities increasing airway pressure (coughing, vomiting, physical effort, etc.) ^3,9. Broad spectrum antibiotics are indicated to prevent infection ^3,6,8,9, as well as feeding restriction ⁹. Whenever possible, pharyngeal mucosa should be sutured to prevent emphysema progression and the entry of opportunistic bacteria ⁹.

In our case, it is possible that the loss of pharyngeal mucosa integrity secondary to tonsils dissection, associated to physical effort during postoperative recovery, were the major causes of the complication.

REFERENCES

Submitted for publication December 2, 2004

Accepted for publication April 4, 2005

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• 07. Miman MC, Ozturan O, Durmus M et al - Cervical subcutaneous emphysema: an unusual complication of adentonsillectomy, Paediatr Anaesth, 2001;11:491-493.
• 08. Braverman I, Rosenmann E, Elidan J - Closed rhinolalia as a symptom of pneumomediastinum after tonsillectomy: a case report and literature review. Otolaryngol Head Neck Surg, 1997;116:551-553.
• 09. Nishino H, Kemmochi M, Kasugai S et al - Subcutaneous emphysema secondary to tonsillectomy: a case report. Auris Nasus Larinx, 2003;30:135-136.
• 10. Hampton SM, Cinnamond MJ - Subcutaneous emphysema as a complication of tonsillectomy, J Laryngol Otol, 1997;111: 1077-1078.
• 11. Castiglia YMM, Machado PRA, Amorin RB et al - Enfisema subcutâneo pós-operatório. Relato de casos. Rev Bras Anestesiol, 1993;43:205-207.
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*

Received from CET/SBA do Hospital Vera Cruz, Campinas, SP

Publication Dates

• Publication in this collection
  24 Oct 2005
• Date of issue
  Aug 2005

History

• Accepted
  04 Apr 2005
• Received
  02 Dec 2004