American Journal of Emergency Medicine 33 (2015) 1842.e1–1842.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Pneumomediastinum presenting as left periorbital subcutaneous emphysema Abstract Idiopathic spontaneous pneumomediastinum is rare but even rarer is associated unilateral periorbital subcutaneous emphysema. There is only 1 known case report noting both of these findings and was associated with endoscopic retrograde cholangiopancreatography complication [1,2]. Isolated periorbital emphysema has been associated with dental procedures [3], facial trauma, and sneezing [4]. It is has also been seen with pneumomediastinum caused by barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. A 52-year-old White male presents to the emergency department with complaint of left eye swelling that occurred overnight without known cause. He was found to have spontaneous idiopathic pneumomediastinum and unilateral periorbital subcutaneous emphysema. Although rare, it is important to rule out subcutaneous air tracking from pneumomediastinum when evaluating unilateral periorbital swelling in an otherwise asymptomatic patient. Idiopathic spontaneous pneumomediastinum is rare but even rarer is associated unilateral periorbital subcutaneous emphysema. There is only 1 known case report noting both of these findings and was associated with endoscopic retrograde cholangiopancreatography complication [1,2]. Isolated periorbital emphysema has been associated with dental procedures [3], facial trauma, and sneezing [4]. It is has also been seen with pneumomediastinum caused by barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. A 52-year-old White male presents to the emergency department with complaint of left eye swelling that occurred overnight (Fig. 1). The patient states that he woke up in the morning, and when he looked in the mirror, his left periorbital soft tissue was swollen. He does not recount any allergic insult. He denies visual disturbance or pain. He has no fever, no rash, and no arthropathy. He denies chest pain, shortness of breath, or wheezing. He does have a chronic cough from smoking cigarettes. His vital signs are normal except a blood pressure of 179/90 mm Hg. Patient has a medical history of tobacco abuse, alcohol abuse, high blood pressure, and rare visits to his primary care doctor. The patient does not have any known allergies or surgical history. He lives alone and drives a truck for a living. On examination, he is a well-developed man of average height lying supine in bed. The smell of tobacco is evident. Left periorbital soft tissue is markedly swollen and shrouding his underlying eyeball. Palpation of the soft tissue is soft, nontender, and normal temperature. Separating the swollen soft tissue with gentle up and down finger traction reveals a normal conjunctiva with intact extraocular muscles and normal vision. Pupil is normal size and reactive to light and accommodation.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
A computed tomogpraphic scan of the face with intravenous contrast was obtained as well as complete blood cell count and basic metabolic panel. Computed tomogpraphic of the face reveals subcutaneous air tracking from mediastinum, neck, and to the left eye. There is no evidence of infection. Computed tomogpraphic of the chest with contrast reveals pneumomediastinum without evidence of pneumothorax or paraesophageal inflammation (Figs. 2–5). The patient was admitted to the hospital for observation. Because of a lack of signs or symptoms, no endoscopic gastroduodenoscopy or bronchoscopy was performed. He was discharged the next day in stable condition with decrease in periorbital emphysema and normal repeat chest x-ray. Although rare, it is important to rule out subcutaneous air tracking from pneumomediastinum when evaluating unilateral periorbital swelling. The differential diagnosis for periorbital subcutaneous emphysema should include dental procedures [3], facial trauma, and sneezing [4]. The differential diagnosis for pneumomediastinum includes barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. Idiopathic spontaneous pneumomediastinum is even rarer in an asymptomatic patient with associated unilateral periorbital subcutaneous emphysema but can occur.
Fig. 1. Left periorbital soft tissue swelling.
1842.e2
J. Orton, E. Collette / American Journal of Emergency Medicine 33 (2015) 1842.e1–1842.e2
Fig. 4. Pneumomediastinum tracking into soft tissues of the neck.
Fig. 2. Left-sided facial subcutaneous free air.
References Jonathan Orton MD Emily Collette FNP Yadkin Valley Community Hospital, 624 W Main St Yadkinville, NC, 27055 E-mail addresses: [email protected] (J. Orton) [email protected] (E. Collette) http://dx.doi.org/10.1016/j.ajem.2015.04.086
Fig. 3. Left-sided facial subcutaneous free air.
[1] Colemont LJ, Pelckmans PA, Moorkens GH, Van Maercke YM. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988;34(6):473–5. [2] Jaiswal Santosh Kumar, Sreevastava Deepak Kumar, Datta Rashmi, Lamba Navdeep Singh. Unusual occurrence of massive subcutaneous emphysema during ERCP under general anaesthesia. Indian J Anaesth 2013;57(6):615–7. [3] Parkar Asif, Medhurst Claire, Irbash Mohammad, Philpott Carl. Periorbital oedema and surgical emphysema, an unusual complication of a dental procedure: a case report. Cases J 2009;2:8108. [4] Gauguet Jean-Marc, Lindquist Patricia A, Shaffer Kitt. Orbital emphysema following ocular trauma and sneezing. Radiol Case Rep 2008;3:124 [Online].
Fig. 5. Pneumomediastinum.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Pneumomediastinum presenting as left periorbital subcutaneous emphysema Abstract Idiopathic spontaneous pneumomediastinum is rare but even rarer is associated unilateral periorbital subcutaneous emphysema. There is only 1 known case report noting both of these findings and was associated with endoscopic retrograde cholangiopancreatography complication [1,2]. Isolated periorbital emphysema has been associated with dental procedures [3], facial trauma, and sneezing [4]. It is has also been seen with pneumomediastinum caused by barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. A 52-year-old White male presents to the emergency department with complaint of left eye swelling that occurred overnight without known cause. He was found to have spontaneous idiopathic pneumomediastinum and unilateral periorbital subcutaneous emphysema. Although rare, it is important to rule out subcutaneous air tracking from pneumomediastinum when evaluating unilateral periorbital swelling in an otherwise asymptomatic patient. Idiopathic spontaneous pneumomediastinum is rare but even rarer is associated unilateral periorbital subcutaneous emphysema. There is only 1 known case report noting both of these findings and was associated with endoscopic retrograde cholangiopancreatography complication [1,2]. Isolated periorbital emphysema has been associated with dental procedures [3], facial trauma, and sneezing [4]. It is has also been seen with pneumomediastinum caused by barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. A 52-year-old White male presents to the emergency department with complaint of left eye swelling that occurred overnight (Fig. 1). The patient states that he woke up in the morning, and when he looked in the mirror, his left periorbital soft tissue was swollen. He does not recount any allergic insult. He denies visual disturbance or pain. He has no fever, no rash, and no arthropathy. He denies chest pain, shortness of breath, or wheezing. He does have a chronic cough from smoking cigarettes. His vital signs are normal except a blood pressure of 179/90 mm Hg. Patient has a medical history of tobacco abuse, alcohol abuse, high blood pressure, and rare visits to his primary care doctor. The patient does not have any known allergies or surgical history. He lives alone and drives a truck for a living. On examination, he is a well-developed man of average height lying supine in bed. The smell of tobacco is evident. Left periorbital soft tissue is markedly swollen and shrouding his underlying eyeball. Palpation of the soft tissue is soft, nontender, and normal temperature. Separating the swollen soft tissue with gentle up and down finger traction reveals a normal conjunctiva with intact extraocular muscles and normal vision. Pupil is normal size and reactive to light and accommodation.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
A computed tomogpraphic scan of the face with intravenous contrast was obtained as well as complete blood cell count and basic metabolic panel. Computed tomogpraphic of the face reveals subcutaneous air tracking from mediastinum, neck, and to the left eye. There is no evidence of infection. Computed tomogpraphic of the chest with contrast reveals pneumomediastinum without evidence of pneumothorax or paraesophageal inflammation (Figs. 2–5). The patient was admitted to the hospital for observation. Because of a lack of signs or symptoms, no endoscopic gastroduodenoscopy or bronchoscopy was performed. He was discharged the next day in stable condition with decrease in periorbital emphysema and normal repeat chest x-ray. Although rare, it is important to rule out subcutaneous air tracking from pneumomediastinum when evaluating unilateral periorbital swelling. The differential diagnosis for periorbital subcutaneous emphysema should include dental procedures [3], facial trauma, and sneezing [4]. The differential diagnosis for pneumomediastinum includes barotrauma, pneumothorax, endoscopic retrograde cholangiopancreatography, and esophageal perforation. Idiopathic spontaneous pneumomediastinum is even rarer in an asymptomatic patient with associated unilateral periorbital subcutaneous emphysema but can occur.
Fig. 1. Left periorbital soft tissue swelling.
1842.e2
J. Orton, E. Collette / American Journal of Emergency Medicine 33 (2015) 1842.e1–1842.e2
Fig. 4. Pneumomediastinum tracking into soft tissues of the neck.
Fig. 2. Left-sided facial subcutaneous free air.
References Jonathan Orton MD Emily Collette FNP Yadkin Valley Community Hospital, 624 W Main St Yadkinville, NC, 27055 E-mail addresses: [email protected] (J. Orton) [email protected] (E. Collette) http://dx.doi.org/10.1016/j.ajem.2015.04.086
Fig. 3. Left-sided facial subcutaneous free air.
[1] Colemont LJ, Pelckmans PA, Moorkens GH, Van Maercke YM. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988;34(6):473–5. [2] Jaiswal Santosh Kumar, Sreevastava Deepak Kumar, Datta Rashmi, Lamba Navdeep Singh. Unusual occurrence of massive subcutaneous emphysema during ERCP under general anaesthesia. Indian J Anaesth 2013;57(6):615–7. [3] Parkar Asif, Medhurst Claire, Irbash Mohammad, Philpott Carl. Periorbital oedema and surgical emphysema, an unusual complication of a dental procedure: a case report. Cases J 2009;2:8108. [4] Gauguet Jean-Marc, Lindquist Patricia A, Shaffer Kitt. Orbital emphysema following ocular trauma and sneezing. Radiol Case Rep 2008;3:124 [Online].
Fig. 5. Pneumomediastinum.
