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Cervicofacial subcutaneous emphysema following dental procedure
  1. Georgios Chrysovitsiotis1,
  2. Aggeliki Boutsikou2,
  3. Paraskevi Kollia3 and
  4. Aristeidis Chrysovergis1
  1. 11st Otorhinolaryngology Department, National and Kapodistrian University of Athens School of Medicine, Athens, Attiki, Greece
  2. 2Otolaryngology Clinic, Hospital Unit of Nafplio, Argos General Hospital, Nafplio, Argolis, Greece
  3. 3Otorhinolaryngology Department, Geniko Nosokomeio Athinon - Elpis, Athens, Attiki, Greece
  1. Correspondence to Georgios Chrysovitsiotis; chrysovi{at}

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A 62-year-old female patient presented to the emergency department with a painless cervicofacial swelling that had reportedly developed progressively over the past 4 hours. The patient had undergone extraction of a first premolar 7 days ago, during which bone damage of the mandibular jaw had been noted. A postextraction inspection of the alveolar ridge had been performed, under local anaesthesia, an hour before the swelling onset. The operating dentist reported using an air syringe, in an attempt to dry the extraction socket and inspect a lesion on the alveolar ridge. The patient complained of mild dysphagia without any other symptom.

Swelling of the right half of the patient’s face, including the maxillary and periorbital region, was noted (figure 1A). The swelling extended to the patient’s right neck, down to the supraclavicular fossa. Palpation of the affected areas elicited crepitus. During oral inspection, the first premolar extraction site was recognised. Mild oedema of the floor of the mouth was also noted. Rhinopharyngolaryngoscopy with flexible fiberscope showed no oedema or protrusion of the pharyngeal walls.

Figure 1

(A) Photograph of the patient showing mild oedema of the palpebral conjunctiva and enhanced skin wrinkling. (B) Axial plane image of the CT scan conducted prior to admission showing air accumulation between tissues at the level of the right zygoma (*), subcutaneously on the right face (**) and at the level of the orbit (***).

Head, neck, and chest CT scans were performed and demonstrated air trapped subcutaneously in the right face, from the orbital soft tissue spaces to the right neck, extending also to the prevertebral space (figures 1B and 2A). The emphysema extended lower to the anterior mediastinum (figure 2B,C).

Figure 2

(A) Axial plane CT image showing extensive air accumulation in the patient’s neck, occupying multiple neck spaces (white arrows), including the prevertebral space (*). (B) Axial plane CT image showing extension of the emphysema to the lower neck and (C) the anterosuperior mediastinum (**).

The patient was admitted for observation and received intravenous amoxicillin with clavulanic acid and metronidazole. The patient’s stay was uneventful and she was discharged, with oral antibiotics, 2 days later. A week later, during follow-up examination, she was asymptomatic and the emphysema had clinically resolved completely. Follow-up CT scan, after 2 weeks, showed no noticeable emphysema.

Cervicofacial subcutaneous emphysema (CSE) consists of abnormal presence of air in the soft tissues of the head and neck. Rarely, it can occur as a potentially serious complication of dental and oral surgical procedures.1 The use of high-pressure air instruments in dentistry as well as air syringes during root canal therapy has repeatedly been demonstrated as the cause of cervicofacial emphysema.2 However, the use of these instruments in a post extraction socket is not common and CSE is, thus, rare following such procedures. In our case, a possible mechanism would also involve the previously mentioned alveolar bone lesion. Therefore, the physician should be aware of this risk before any procedure requiring the use of such instruments and should take appropriate measures to minimise this complication.

Crepitus is a pathognomonic sign of CSE.3 Therefore, it should be recognised by every physician performing invasive or surgical procedures in the upper aerodigestive tract. CSE should always be considered when a patient develops a facial or neck swelling following such a procedure. It can occur either immediately after the procedure or several hours later.4

CSE is usually a self-limited condition and does not require any special treatment. However, potential life-threatening complications can occur. Neck spaces communicate through fascial planes with each other and with the mediastinum.5 Air accumulation can lead to pneumomediastinum or pneumopericardium development.6–8 Dissemination of oral micro-organisms can cause neck or mediastinal infections. Air embolism has also been reported in the literature.9 Therefore, close monitoring is necessary in these cases, until the emphysema has resolved.

Learning points

  • The use of high-pressure air instruments can, uncommonly, cause cervicofacial subcutaneous emphysema (CSE).

  • A compromised alveolar bone integrity can be a rare potential route for CSE development, when working on a post extraction socket.

  • Although usually self-limited, CSE can have life-threatening complications.

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  • Contributors All authors are clinicians who were involved in the diagnosis and treatment of the case. AC was the primary responsible doctor. GC, AB and PK have reviewed the literature and written a first draft that was edited following comments from the primary responsible doctor. All authors approved the final version of the manuscript and agree to the BMJ Case Reports’ submission policies.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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