AM ER IC AN JOURNAL OF OT OLARYNGOLOGY – H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 2 99– 3 0 2
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Late presentation of subcutaneous emphysema and pneumomediastinum following elective tonsillectomy☆,☆☆ Daniel D. Tran, MD a,⁎, Philip D. Littlefield, MD b a b
Major, Medical Corps, US Army; Department of Otolaryngology; Tripler Army Medical Center; Honolulu, Hawaii Lieutenant Colonel, Medical Corps, US Army; Chief, Otology/Neurotology; Tripler Army Medical Center; Honolulu, Hawaii
ARTI CLE I NFO
A BS TRACT
Article history:
Subcutaneous emphysema and pneumomediastinum are rare complications following
Received 21 October 2014
elective tonsillectomy. Although the mechanism of injury is unclear, air is thought to enter through either the buccopharyngeal mucosa during surgery or via alveolar rupture during positive pressure ventilation. Patients typically present immediately after surgery or upon anesthesia emergence. We describe a case of delayed pneumomediastinum in a 30 year-old female who presented 4 days after surgery. With only one other case described, we review the literature and remind the reader to be cognizant of this late complication. Published by Elsevier Inc.
1.
Introduction
Physicians and their patients have long considered tonsillectomy a quick and simple surgery, but the procedure has always had its risks. The risks typically discussed with patients include bleeding, infection, and dehydration, while less commonly discussed complications include glossopharyngeal nerve and carotid artery injuries [1]. An extremely rare complication, first described in 1950, is subcutaneous emphysema with subsequent pneumomediastinum [2]. The mechanism by which air enters the subcutaneous tissue of the neck and mediastinum after surgery is unknown, but it is thought to occur through the thin buccopharyngeal mucosa of the tonsillar fossae. Alveolar rupture as a result of positive pressure ventilation during anesthetic emergence is also hypothesized to have occurred in a small number of described cases. We describe one of only
☆
two cases of post-tonsillectomy pneumomediastinum with a delayed presentation of several days, and review the literature on the topic.
2.
Case presentation
A healthy 30 year-old woman had an elective tonsillectomy for chronic tonsillitis with frequent tonsillith production. Nothing unusual was noted during the surgery, which was performed under general anesthesia using a preformed oral endotracheal tube. The tonsils were removed using monopolar electrocautery, with hemostasis easily achieved using the same device. Both tonsils were adherent to the tonsillar fossae, as is typical with adult tonsillectomy for chronic disease. The patient had a bout of coughing immedi-
Each of the authors has contributed to, read and approved this manuscript. This manuscript is original and it, or any part of it, has not been previously published; nor is it under consideration for publication elsewhere. ⁎ Corresponding author at: Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, Hawaii, Tel.: + 1 808 433 3169; fax + 1 808 4339033. E-mail address: [email protected] (D.D. Tran). ☆☆
http://dx.doi.org/10.1016/j.amjoto.2014.10.034 0196-0709/Published by Elsevier Inc.
300
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 2 99 – 3 0 2
ately after extubation, but it quickly resolved in the postanesthesia care unit. She was observed for four hours in the recovery area (per routine), and then was discharged home with good pain control, able to drink and tolerate a soft diet. Four days after surgery, the patient presented to the emergency department with progressive neck pain and a persistent dry cough. She noted fullness of the right side of her neck with a “popping” sensation on palpation. She appeared uncomfortable, but was not in any acute respiratory distress. Physical examination showed the expected fibrinous exudate covering both tonsillar fossae, without any evidence of a mucosal tear or dehiscence. There was no bleeding or any clot. A chest x-ray was performed showing subcutaneous air within the right neck tracking into the mediastinum (Fig. 1). There was no mediastinal shift, pneumothorax, or any evidence of focal airspace consolidation. Computerized tomography (CT) showed emphysema within the deep soft tissues of the neck from the hypopharynx to the mediastinum (Fig. 2). Based on these findings, the patient was admitted for observation and treated for a cough that appeared to be exacerbating the air collection. She was also placed on intravenous clindamycin in order to prevent a mediastinal infection. Cardiothoracic surgery was consulted with the recommendation of close observation with daily imaging to follow her progress. A repeat CT of the neck on her third day of hospitalization showed decreased subcutaneous air. Despite this, she had persistent, marked difficulty swallowing and had poor oral intake. Speech pathology was consulted and performed a modified barium swallow study. This study was normal without evidence of dysphagia or aspiration, and thus, she was continued on her liquid/ pureed diet. Once tolerating oral intake, she was discharged home. She was asymptomatic and in good health on followup one week later.
Fig. 1 – Frontal portable chest radiograph demonstrating linear lucency under the pericardium with right sided subcutaneous emphysema.
3.
Discussion
Subcutaneous emphysema and pneumomediastinum have both been described following tonsillectomy, but they are rare complications. Air may enter the interstitial spaces of the neck and chest through a mucosal violation anywhere along the airway — from the oropharynx to the terminal alveoli. Most case reports have proposed one of two routes of air penetration after a tonsillectomy: (1) directly through the tonsillar fossae, or (2) via rupture of marginal alveoli from excessive intrapulmonary pressure [3]. The direct route through the tonsillar fossae requires air to track through several layers. The floor of the tonsillar fossa consists of a layer of fascia known as the pharyngobasilar fascia. This fascia covers the superior constrictor muscle overlying the middle layer of the deep cervical fascia, also known as the buccopharyngeal fascia. Tonsillectomy involves dissection just superficial to the pharyngobasilar fascia, but may create deeper defects due to adhesions within the tonsillar bed [4]. Penetration of this deep (yet flimsy) layer gives access to the parapharyngeal neck space, resulting in subcutaneous emphysema. Because the parapharyngeal and retropharyngeal spaces are connected, air within the neck can track into the chest and cause a pneumomediastinum. In contrast, air may initially enter the chest via rupture of an alveolar bleb. This may occur spontaneously following abrupt increases in intrapulmonary pressure, often after sneezing, coughing, or retching/vomiting [5]. Additionally, a laryngocele or traumatic intubation may create a defect that allows free air to enter the peritracheal tissue upon positive pressure ventilation, or other sudden increases in intrathoracic pressure. Entry of air in these more distal parts of the tracheobronchial tree is possible with most airway procedures, not just tonsillectomy. A review of the English-language literature via MEDLINE reveals 14 reported cases of subcutaneous emphysema and pneumomediastinum following tonsillectomy (Table 1). This includes both the pediatric and adult populations. When both conditions occur together, the order in which the symptoms present helps to identify the site of injury. Most patients with defects involving the tonsillar fossae presented acutely with facial and/or neck swelling [6]. Air may subsequently track caudally to the mediastinum, with the development of dyspnea, dysphagia, chest and back pain, and possible respiratory distress. Cases involving violation of more distal aspects of the airway may initially present with chest pain or respiratory symptoms, with neck and facial swelling developing as the air moves more cephalad [7]. This has been described immediately following anesthesia induction, prior to any manipulation of the tonsils, but it is more likely to present after surgery because the initial signs and symptoms are subtle [8]. In one series, the diagnosis was made from 15 minutes to 14 hours after surgery [3]. In comparison, the time to diagnosis for cases of subcutaneous emphysema alone ranged from intraoperative detection to the first postoperative day [3]. To date, only one case of delayed cervical subcutaneous emphysema and pneumomediastinum has been described following tonsillectomy [9]. Our patient is the only other case in which symptoms did not present within the first
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY – H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 2 99– 3 0 2
301
Fig. 2 – Axial CT of the neck showing air within the deep soft tissues of the neck from level of the hypopharynx down to the mediastinum.
postoperative day. In both cases, the patients did not display any immediate signs of swelling or breathing difficulties tosuggest either subcutaneous emphysema or pneumomediastinum. Both patients presented four days after surgery with neck fullness, decreased range of motion, and difficulty swallowing. We speculate that given the difficult dissection with adhesions in the tonsillar bed, a small fascial defect was created, allowing small amounts of air to enter the neck with coughing. This amount of air may have been small enough to require several days to accumulate. Although neither patient had life-threatening cardiopulmonary complications, airway obstruction as well as
cardiac arrest secondary to tension pneumomediastinum can occur [7]. Of the 14 described cases, four required acute airway management or further surgery. Treatment involves close monitoring of the airway with regular imaging to follow the extent of the emphysema. The patient should be placed on bedrest with avoidance of any activity that may increase pressure within the upper airway such as vomiting, straining, or in our patient, coughing. Broad-spectrum antibiotic prophylaxis is typically given to prevent infection secondary to migration of oral cavity flora through the mucosal defect. Additionally, oxygen may be used to expedite nitrogen absorption within the air space [10].
Table 1 – Reported cases of subcutaneous emphysema and pneumomediastinum following tonsillectomy. Year Authors
Sex/age Technique
Symptoms
Time to presentation
Treatment
10 hours
Antibiotics Antibiotics Thoracotomy, transfusion
1950 1954 1955
Silverman et al. [2] M/8 Knutson and Ouellette [12] M/6 Ferguson et al. [13] F/4
Snare
Neck swelling, dyspnea
?
Dyspnea, abdominal distension, 40 minutes cardiac shift
1958 1976
Pratt et al. Prupas and Fordham [1]
F/9 M/22
Snare
1995 1997
Vos et al. [14] Braverman et al. [5]
F/5 F/22
? Snare, cautery
2003 2004 2004 2005 2005
Marioni et al. [7] Yammine et al. [9] Stewart et al. [3] Shine et al. [10] Panerari et al. [6]
F/34 M/36 F/22 F/7 F/31
Dyspnea, neck swelling, chest pain Abdominal distension Dyspnea, chest pain, neck swelling Cheek/chin swelling Neck swelling, dysphagia Cheek/perorbital swelling Neck/facial swelling Dyspnea, stridor
2008
Kim et al. [4]
F/36
2013
Koukoutsis et al. [15]
F/21
2013
Present surgery
F/30
?, cautery Snare, cautery Cautery Cautery Cold steel, bipolar cautery Cautery Neck swelling, submandibular pain Cautery Neck/facial swelling, submandibular pain Cautery None
14 hours
Thoracotomy Observation
30 minutes 2 hours
Needle decompression Observation
5 hours 4 days < 1 hour Recovery room Extubation POD#1
Antibiotics Antibiotics Antibiotics Antibiotics, observation Suture closure, tracheostomy, antibiotics Antibiotics
1 hour
Antibiotics
4 days
Antibiotics, observation
302
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 2 99 – 3 0 2
4.
Conclusion
This unusual case should increase awareness that subcutaneous emphysema and pneumomediastinum may present late after tonsillectomy. Whereas these complications may be expected in the immediate postoperative period, this shows that an initially asymptomatic patient may still present several days after surgery. Because swelling, odynophagia, and dysphagia are already common complaints following tonsillectomy, the provider should have a heightened sense of awareness, especially with any mention of breathing difficulties or crepitus. Additionally, because of the increased risk of developing either of these conditions with a positive pressure event, providers should help to ensure smooth emergences by working closely with their anesthesia colleagues. There should be good communication to ensure the patient does not wake before completion of surgery, and the airway should be suctioned with an orogastric tube to avoid laryngeal irritation upon emergence [11]. Finally, in the adult with adherent tonsils, assure a meticulous dissection in order to preserve the fascial layers. Whatever the pathology or technique used, an increased awareness and close observation will help ensure these potential complications do not develop into life-threatening situations.
REFERENCES
[1] Prupas HM, Fordham SD. Emphysema secondary to tonsillectomy. Laryngoscope 1977;87:1134–6. [2] Silverman JJ, Talbot TJ, McClean RW. Mediastinal emphysema following tonsillectomy. Dis Chest 1953;23:397–402. [3] Stewart AE, Brewster DF, Berstein PE. Subcutaneous emphysema and pneumomediastinum complicating tonsillectomy. Arch Otolaryngol Head Neck Surg 2004;130:1324–7.
[4] Kim JP, Park JJ, Kang HS. Subcutaneous emphysema and pneumomediastinum after tonsillectomy. Am J Otolaryngol 2010;31:212–5. [5] 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;116:551–3. [6] Panerari AC, Soter AC, Porta da Silva FL, et al. Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report. Braz J Otorhinolaryngol 2005;71: 94–6. [7] Marioni G, Filippis CD, Tregnaghi A, et al. Cervical emphysema and pneumomediastinum after tonsillectomy: it can happen. Otolaryngol Head Neck Surg 2003;128:298–300. [8] Jash DK. An unusual complication during adeno-tonsillectomy. J Laryngol Otol 1973;87:191–4. [9] Yammine NV, Alherabi A, Gerin-Lajoie J. Post-tonsillectomy subcutaneous emphysema and pneumomediastinum. Am J Otolaryngol 2004;33:403–4. [10] Shine NP, Sader C, Coates H. Cervicofacial emphysema and pneumomediastinum following pediatric adenotonsillectomy: a rare complication. Int J Pediatr Otorhinolaryngol 2005;69:1579–82. [11] Hung MH, Shih PY, Yang YM, et al. Cervicofacial subcutaneous emphysema following tonsillectomy: implications for anesthesiologists. Acta Anaesthesiol Taiwan 2009;47:134–7. [12] Knutson RC, Ouellette AJ. Subcutaneous emphysema following tonsillectomy and adenoidectomy. Minn Med 1954;37:877–9. [13] Ferguson CC, McGarry PM, Beckman IH, et al. Surgical emphysema complicating tonsillectomy and dental extraction. Can Med Assoc J 1955;72:847–8. [14] Vos GD, Marres EH, Hineman E, et al. Tension penumoperitoneum as an early complication after adenotonsillectomy. J Laryngol Otol 1995;109:440–1. [15] Koukoutsis G, Balatsouras DG, Ganelis P, et al. Subcutaneous emphysema and pneumomediastinum after tonsillectomy. Case Rep Otolaryngol 2013:154857. http://dx.doi.org/10.1155/ 2013/154857.
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Late presentation of subcutaneous emphysema and pneumomediastinum following elective tonsillectomy☆,☆☆ Daniel D. Tran, MD a,⁎, Philip D. Littlefield, MD b a b
Major, Medical Corps, US Army; Department of Otolaryngology; Tripler Army Medical Center; Honolulu, Hawaii Lieutenant Colonel, Medical Corps, US Army; Chief, Otology/Neurotology; Tripler Army Medical Center; Honolulu, Hawaii
ARTI CLE I NFO
A BS TRACT
Article history:
Subcutaneous emphysema and pneumomediastinum are rare complications following
Received 21 October 2014
elective tonsillectomy. Although the mechanism of injury is unclear, air is thought to enter through either the buccopharyngeal mucosa during surgery or via alveolar rupture during positive pressure ventilation. Patients typically present immediately after surgery or upon anesthesia emergence. We describe a case of delayed pneumomediastinum in a 30 year-old female who presented 4 days after surgery. With only one other case described, we review the literature and remind the reader to be cognizant of this late complication. Published by Elsevier Inc.
1.
Introduction
Physicians and their patients have long considered tonsillectomy a quick and simple surgery, but the procedure has always had its risks. The risks typically discussed with patients include bleeding, infection, and dehydration, while less commonly discussed complications include glossopharyngeal nerve and carotid artery injuries [1]. An extremely rare complication, first described in 1950, is subcutaneous emphysema with subsequent pneumomediastinum [2]. The mechanism by which air enters the subcutaneous tissue of the neck and mediastinum after surgery is unknown, but it is thought to occur through the thin buccopharyngeal mucosa of the tonsillar fossae. Alveolar rupture as a result of positive pressure ventilation during anesthetic emergence is also hypothesized to have occurred in a small number of described cases. We describe one of only
☆
two cases of post-tonsillectomy pneumomediastinum with a delayed presentation of several days, and review the literature on the topic.
2.
Case presentation
A healthy 30 year-old woman had an elective tonsillectomy for chronic tonsillitis with frequent tonsillith production. Nothing unusual was noted during the surgery, which was performed under general anesthesia using a preformed oral endotracheal tube. The tonsils were removed using monopolar electrocautery, with hemostasis easily achieved using the same device. Both tonsils were adherent to the tonsillar fossae, as is typical with adult tonsillectomy for chronic disease. The patient had a bout of coughing immedi-
Each of the authors has contributed to, read and approved this manuscript. This manuscript is original and it, or any part of it, has not been previously published; nor is it under consideration for publication elsewhere. ⁎ Corresponding author at: Tripler Army Medical Center, 1 Jarrett White Road, Tripler AMC, Hawaii, Tel.: + 1 808 433 3169; fax + 1 808 4339033. E-mail address: [email protected] (D.D. Tran). ☆☆
http://dx.doi.org/10.1016/j.amjoto.2014.10.034 0196-0709/Published by Elsevier Inc.
300
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 2 99 – 3 0 2
ately after extubation, but it quickly resolved in the postanesthesia care unit. She was observed for four hours in the recovery area (per routine), and then was discharged home with good pain control, able to drink and tolerate a soft diet. Four days after surgery, the patient presented to the emergency department with progressive neck pain and a persistent dry cough. She noted fullness of the right side of her neck with a “popping” sensation on palpation. She appeared uncomfortable, but was not in any acute respiratory distress. Physical examination showed the expected fibrinous exudate covering both tonsillar fossae, without any evidence of a mucosal tear or dehiscence. There was no bleeding or any clot. A chest x-ray was performed showing subcutaneous air within the right neck tracking into the mediastinum (Fig. 1). There was no mediastinal shift, pneumothorax, or any evidence of focal airspace consolidation. Computerized tomography (CT) showed emphysema within the deep soft tissues of the neck from the hypopharynx to the mediastinum (Fig. 2). Based on these findings, the patient was admitted for observation and treated for a cough that appeared to be exacerbating the air collection. She was also placed on intravenous clindamycin in order to prevent a mediastinal infection. Cardiothoracic surgery was consulted with the recommendation of close observation with daily imaging to follow her progress. A repeat CT of the neck on her third day of hospitalization showed decreased subcutaneous air. Despite this, she had persistent, marked difficulty swallowing and had poor oral intake. Speech pathology was consulted and performed a modified barium swallow study. This study was normal without evidence of dysphagia or aspiration, and thus, she was continued on her liquid/ pureed diet. Once tolerating oral intake, she was discharged home. She was asymptomatic and in good health on followup one week later.
Fig. 1 – Frontal portable chest radiograph demonstrating linear lucency under the pericardium with right sided subcutaneous emphysema.
3.
Discussion
Subcutaneous emphysema and pneumomediastinum have both been described following tonsillectomy, but they are rare complications. Air may enter the interstitial spaces of the neck and chest through a mucosal violation anywhere along the airway — from the oropharynx to the terminal alveoli. Most case reports have proposed one of two routes of air penetration after a tonsillectomy: (1) directly through the tonsillar fossae, or (2) via rupture of marginal alveoli from excessive intrapulmonary pressure [3]. The direct route through the tonsillar fossae requires air to track through several layers. The floor of the tonsillar fossa consists of a layer of fascia known as the pharyngobasilar fascia. This fascia covers the superior constrictor muscle overlying the middle layer of the deep cervical fascia, also known as the buccopharyngeal fascia. Tonsillectomy involves dissection just superficial to the pharyngobasilar fascia, but may create deeper defects due to adhesions within the tonsillar bed [4]. Penetration of this deep (yet flimsy) layer gives access to the parapharyngeal neck space, resulting in subcutaneous emphysema. Because the parapharyngeal and retropharyngeal spaces are connected, air within the neck can track into the chest and cause a pneumomediastinum. In contrast, air may initially enter the chest via rupture of an alveolar bleb. This may occur spontaneously following abrupt increases in intrapulmonary pressure, often after sneezing, coughing, or retching/vomiting [5]. Additionally, a laryngocele or traumatic intubation may create a defect that allows free air to enter the peritracheal tissue upon positive pressure ventilation, or other sudden increases in intrathoracic pressure. Entry of air in these more distal parts of the tracheobronchial tree is possible with most airway procedures, not just tonsillectomy. A review of the English-language literature via MEDLINE reveals 14 reported cases of subcutaneous emphysema and pneumomediastinum following tonsillectomy (Table 1). This includes both the pediatric and adult populations. When both conditions occur together, the order in which the symptoms present helps to identify the site of injury. Most patients with defects involving the tonsillar fossae presented acutely with facial and/or neck swelling [6]. Air may subsequently track caudally to the mediastinum, with the development of dyspnea, dysphagia, chest and back pain, and possible respiratory distress. Cases involving violation of more distal aspects of the airway may initially present with chest pain or respiratory symptoms, with neck and facial swelling developing as the air moves more cephalad [7]. This has been described immediately following anesthesia induction, prior to any manipulation of the tonsils, but it is more likely to present after surgery because the initial signs and symptoms are subtle [8]. In one series, the diagnosis was made from 15 minutes to 14 hours after surgery [3]. In comparison, the time to diagnosis for cases of subcutaneous emphysema alone ranged from intraoperative detection to the first postoperative day [3]. To date, only one case of delayed cervical subcutaneous emphysema and pneumomediastinum has been described following tonsillectomy [9]. Our patient is the only other case in which symptoms did not present within the first
AM ER IC AN JOURNAL OF OT OLARYNGOLOGY – H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 2 99– 3 0 2
301
Fig. 2 – Axial CT of the neck showing air within the deep soft tissues of the neck from level of the hypopharynx down to the mediastinum.
postoperative day. In both cases, the patients did not display any immediate signs of swelling or breathing difficulties tosuggest either subcutaneous emphysema or pneumomediastinum. Both patients presented four days after surgery with neck fullness, decreased range of motion, and difficulty swallowing. We speculate that given the difficult dissection with adhesions in the tonsillar bed, a small fascial defect was created, allowing small amounts of air to enter the neck with coughing. This amount of air may have been small enough to require several days to accumulate. Although neither patient had life-threatening cardiopulmonary complications, airway obstruction as well as
cardiac arrest secondary to tension pneumomediastinum can occur [7]. Of the 14 described cases, four required acute airway management or further surgery. Treatment involves close monitoring of the airway with regular imaging to follow the extent of the emphysema. The patient should be placed on bedrest with avoidance of any activity that may increase pressure within the upper airway such as vomiting, straining, or in our patient, coughing. Broad-spectrum antibiotic prophylaxis is typically given to prevent infection secondary to migration of oral cavity flora through the mucosal defect. Additionally, oxygen may be used to expedite nitrogen absorption within the air space [10].
Table 1 – Reported cases of subcutaneous emphysema and pneumomediastinum following tonsillectomy. Year Authors
Sex/age Technique
Symptoms
Time to presentation
Treatment
10 hours
Antibiotics Antibiotics Thoracotomy, transfusion
1950 1954 1955
Silverman et al. [2] M/8 Knutson and Ouellette [12] M/6 Ferguson et al. [13] F/4
Snare
Neck swelling, dyspnea
?
Dyspnea, abdominal distension, 40 minutes cardiac shift
1958 1976
Pratt et al. Prupas and Fordham [1]
F/9 M/22
Snare
1995 1997
Vos et al. [14] Braverman et al. [5]
F/5 F/22
? Snare, cautery
2003 2004 2004 2005 2005
Marioni et al. [7] Yammine et al. [9] Stewart et al. [3] Shine et al. [10] Panerari et al. [6]
F/34 M/36 F/22 F/7 F/31
Dyspnea, neck swelling, chest pain Abdominal distension Dyspnea, chest pain, neck swelling Cheek/chin swelling Neck swelling, dysphagia Cheek/perorbital swelling Neck/facial swelling Dyspnea, stridor
2008
Kim et al. [4]
F/36
2013
Koukoutsis et al. [15]
F/21
2013
Present surgery
F/30
?, cautery Snare, cautery Cautery Cautery Cold steel, bipolar cautery Cautery Neck swelling, submandibular pain Cautery Neck/facial swelling, submandibular pain Cautery None
14 hours
Thoracotomy Observation
30 minutes 2 hours
Needle decompression Observation
5 hours 4 days < 1 hour Recovery room Extubation POD#1
Antibiotics Antibiotics Antibiotics Antibiotics, observation Suture closure, tracheostomy, antibiotics Antibiotics
1 hour
Antibiotics
4 days
Antibiotics, observation
302
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 2 99 – 3 0 2
4.
Conclusion
This unusual case should increase awareness that subcutaneous emphysema and pneumomediastinum may present late after tonsillectomy. Whereas these complications may be expected in the immediate postoperative period, this shows that an initially asymptomatic patient may still present several days after surgery. Because swelling, odynophagia, and dysphagia are already common complaints following tonsillectomy, the provider should have a heightened sense of awareness, especially with any mention of breathing difficulties or crepitus. Additionally, because of the increased risk of developing either of these conditions with a positive pressure event, providers should help to ensure smooth emergences by working closely with their anesthesia colleagues. There should be good communication to ensure the patient does not wake before completion of surgery, and the airway should be suctioned with an orogastric tube to avoid laryngeal irritation upon emergence [11]. Finally, in the adult with adherent tonsils, assure a meticulous dissection in order to preserve the fascial layers. Whatever the pathology or technique used, an increased awareness and close observation will help ensure these potential complications do not develop into life-threatening situations.
REFERENCES
[1] Prupas HM, Fordham SD. Emphysema secondary to tonsillectomy. Laryngoscope 1977;87:1134–6. [2] Silverman JJ, Talbot TJ, McClean RW. Mediastinal emphysema following tonsillectomy. Dis Chest 1953;23:397–402. [3] Stewart AE, Brewster DF, Berstein PE. Subcutaneous emphysema and pneumomediastinum complicating tonsillectomy. Arch Otolaryngol Head Neck Surg 2004;130:1324–7.
[4] Kim JP, Park JJ, Kang HS. Subcutaneous emphysema and pneumomediastinum after tonsillectomy. Am J Otolaryngol 2010;31:212–5. [5] 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;116:551–3. [6] Panerari AC, Soter AC, Porta da Silva FL, et al. Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report. Braz J Otorhinolaryngol 2005;71: 94–6. [7] Marioni G, Filippis CD, Tregnaghi A, et al. Cervical emphysema and pneumomediastinum after tonsillectomy: it can happen. Otolaryngol Head Neck Surg 2003;128:298–300. [8] Jash DK. An unusual complication during adeno-tonsillectomy. J Laryngol Otol 1973;87:191–4. [9] Yammine NV, Alherabi A, Gerin-Lajoie J. Post-tonsillectomy subcutaneous emphysema and pneumomediastinum. Am J Otolaryngol 2004;33:403–4. [10] Shine NP, Sader C, Coates H. Cervicofacial emphysema and pneumomediastinum following pediatric adenotonsillectomy: a rare complication. Int J Pediatr Otorhinolaryngol 2005;69:1579–82. [11] Hung MH, Shih PY, Yang YM, et al. Cervicofacial subcutaneous emphysema following tonsillectomy: implications for anesthesiologists. Acta Anaesthesiol Taiwan 2009;47:134–7. [12] Knutson RC, Ouellette AJ. Subcutaneous emphysema following tonsillectomy and adenoidectomy. Minn Med 1954;37:877–9. [13] Ferguson CC, McGarry PM, Beckman IH, et al. Surgical emphysema complicating tonsillectomy and dental extraction. Can Med Assoc J 1955;72:847–8. [14] Vos GD, Marres EH, Hineman E, et al. Tension penumoperitoneum as an early complication after adenotonsillectomy. J Laryngol Otol 1995;109:440–1. [15] Koukoutsis G, Balatsouras DG, Ganelis P, et al. Subcutaneous emphysema and pneumomediastinum after tonsillectomy. Case Rep Otolaryngol 2013:154857. http://dx.doi.org/10.1155/ 2013/154857.
