C L IN IC A L
REPORTS
Soft tissue emphysema C . R o n a ld S p a u ld in g , D D S
A case of soft tissue emphysema as a complication of a routine dental restoration is presented. The causes, the differential diagnoses of hematoma, allergic reaction, inflammation and infection, and the management of emphysema are also discussed.
TJL issue emphysema refers to the
presence of air or gas in the soft tis sue.1 Many causes have been recog nized and reported and include fa cial,1,2 cervical, 1 and thoracic3 in jury, tracheostomy,1 and various procedures and conditions related to dentistry. Dental literature contains cases of particular interest because of the causes described. The causes can be the introduction of hydrogen peroxide into the soft tissues during endodontic therapy4 with the sub sequent release of free oxygen, forced free air from a dental syringe5 or air-driven turbine handpiece,6'7 self-induced emphysema after den tal extraction,8 or intraoral injury.9 Although the potential for soft tis sue emphysema during a surgical procedure is realized, the following case shows the existence of a similar potential during less invasive and seemingly more benign restorative dental procedures.
Report o f case During a routine restorative dental pro cedure, swelling was seen in the left in fraorbital region of a 17-year-old girl. The dentist sought immediate consultation. The dentist had adm inistered a local anesthetic about an hour before this in ci dent and had p roceeded w ith the restora tive treatment in the m axillary left quad rant. He said that access and visibility were lim ited in certain regions and that w ithin seconds o f drying on e area w ith the air syringe the sw elling w as noticed. W hen the patient was first seen, she seem ed to be extremely apprehensive but apparently healthy. Her m edical history
was essentially noncontributory, and she had n o k n ow led ge o f allergy to any m edications, in clu d in g local anesthetics. Examination show ed a large, soft sw elling w h ich extended from the left in fraorbital to the b u cca l region (Illustra tion). Other than the extreme anxiety n oticed initially, the patient had n o other sp ecific com plaints at that time. Skin rash, itching, other sw elling, or respira tory im pairm ents w ere not evident. The facial sw elling was nonpulsatile, and no bruit was heard w ith a stethoscope. In traoral exam ination disclosed a tem porarily restored m axillary left second m olar and a small (1-2 mm ) abrasion in the left buccal m ucosa.
JADA, V ol. 98, A p ril 1979 ■ 587
C L IN IC A L
REPORTS
Careful palpation o f the extraoral swelling disclosed fine crepitus throughout the region. Intraoral inspec tion at the time of extraoral palpation also showed several small bubbles exit ing from the mucosal abrasion. The diagnosis o f soft tissue em physema was made from these findings, and the portal of entry was assumed to be the buccal mucosal lesion. This assump tion was confirmed by blunt exploration through the wound into the cheek. The nature of this condition and palliative home-care measures (including anal gesics and moist heat applied to the re gion) were explained to the patient and her family. A seven-day regimen of prophylactic penicillin was begun, and the patient was discharged. When the patient was seen a week la ter, the swelling was completely resolved and the patient was asymptomatic. There was no evidence of crepitus in the af fected soft tissue and the mucosal injury noticed a week earlier was completely healed. The patient was discharged and has had no residual effect or recurrence.
Discussion T h e appearance of soft tissue em physem a d u rin g an otherw ise u n com plicated restorative procedure can be frig htenin g. T h e p atien t m ay in itia lly feel p ain or a sense of fu ll ness in the facial/cervical region and m ay even have d iffic u lty breath in g .4,7,10 R apid sw elling can fu rth er u nn erve p atien t and dentist. A d iffe ren tial diagnosis w ith the appearance of these signs could in clude hem atom a, allergic reaction, in fla m m a tio n and infection, as w e ll as em physem a. In flam m a to ry reac tio n or infection can be ru led out im m e d ia te ly because of the ra p id sw e llin g seen w ith em physem a. A ra p id ly occurring allergic reaction can m im ic em physem a durin g its early stages so patients m ust be ob served and treated should fu rth er signs o f allergic reaction such as p ru ritus, u rticaria, w heezing , or ra p id onset of cardiovascular col lapse occur. Perhaps the most d if fic u lt co n d itio n to ru le out w ith a ra p id sw e llin g w o u ld be hem atom a. T h e facial region is h ig h ly vascular so an inadverten t or unrecognized
588 ■ JADA, V ol. 98, A p ril 1979
accident w ith a sharp instrum ent co u ld result in a vascular in ju ry. A p ulsatile nature o f the sw e llin g or a b ru it heard w ith a stethoscope w o u ld suggest a hem orrhagic o rigin and ap p ropriate measures should be taken im m e d ia tely. T h e most useful sign in diagnosing em physem a is the crepitis. T h is feelin g o f m u ltip le gas bubbles or a crackling sensation w ith p alp a tio n is alm ost charac teristic of em physem a. F in a lly , radiographs can often show the air trapp ed in the soft tissue.5 O nce referred to as u n im p o rtan t or w ith o u t d an ger,11 the p o tential for serious sequelae is n o w recognized and should direct the m anagem ent o f em physem a. S im ultaneous in tro ductio n o f contam inated or septic m aterial u n d e r pressure can lead to in fe c tio n .1,12 L ocalized facial infec tions can become w idespread through fascial planes and potential spaces.13 Even in the absence of fra n k infection , the compressed air can spread th ro ug h the same ana to m ic routes w ith serious conse quences.10 Because of the p otential for infec tio n , treatm en t should be directed at pro ph ylactic m anagem ent. T h e p or tal of en try should be kept free of co n tam in ation and an tibio tic cover age should be in s titu ted im m ediately. T h e use o f m oist heat m ay be effective in increasing the vascular absorption o f free air though its p rim a ry advantage is probably as a placebo. F in a lly the p atien t m ust be w arn e d to avoid any intrao ral pressure— such as b lo w in g on a m usical instru m en t— w h ic h m ig h t introduce m ore air, or debris or both into the soft tissue. A d d ed discom fort can be con tro lled w ith analgesics i f needed. W ith o u t com plicatio n s the em physem a can be expected to resolve spontaneously in fiv e to seven days.
Sum mary M a n y cases of soft tissue em physem a have been reported; it is recognized as a com m on surgical and dental com plication. T his report
adds to the n um ber o f recorded cases and em phasizes the p otential for em physem a w ith the use of h ig h pressure dental instrum ents. I t also shows that the p o in t o f en try of a ir m ay be overlooked and w il l there fore delay diagnosis. Proper diagnosis and reco gn itio n o f the p o tential for w idespread sec ondary in fe ctio n dictate the m a n agem ent o f em physem a. I f any doubt should exist, consultation should be obtained w ith o u t hesitation.
Dr. Spaulding practices oral and m axillofacial surgery in St. Johnsbury, Vt. A ddress re quests for reprints to Dr. C. Ronald Spaulding, M edical Arts Building, Hospital Drive, St. Johnsbury, Vt 05819. 1. Irby, W.B. Current advances in oral surgery, vol 2. St. Louis, C. V. Mosby Co., 1977, pp 320-321. 2. Oswalt, T.G. Emphysema: case histories and conclusions. J M iss Dent Assoc 19:12-18, 1963. 3. Schwartz, S.I., and others, (eds.). Princi ples of surgery, ed 2, vol 1. New York, McGrawCo., p 660. 4. Bhet, K.S. Tissue em physem a caused by hydrogen peroxide. Oral Surg 38:304-307, 1974. 5. Poyton, H.G., and Arora, B.K. Radiologic evidence of surgical emphysem a. Report of a case. Oral Surg 35:129-131, 1973. 6. Segal, M., and Norton, H.D. Surgical em physem a occurring during conservative dental surgery. Dent Pract 17:274-276, 1967. 7. Hayduk, S.; Bennett, C.R.; and M onheim, L.M. Subcutaneous em physem a after operative dentistry: report of case. JADA 80(6):1362, 1970. 8. Shovelton, D.S. Surgical em physem a as a com plication of dental operations. Br Dent J 102:125-129, 1957. 9. Lee, J.L., Jr., and Bordenca, C.M. Self induced air em physem a of the face and neck. Oral Surg 36:603-605, 1973. 10. M arlette, R.N. M ediastinal em physem a follow ing tooth extraction: report of a case. Oral Surg 16:116-119, 1963. 11. Barber, J.W., and Bum s, J.B. Subcuta neous em physem a of the face and neck after dental restoration. JADA 75:167-169, 1967. 12. Kruger, Gustav O. Textbook of oral surgery, ed 4. St. Louis, C. V. Mosby Co., 1974, pp 183-184. 13. Sicher, H., and DuBrul, E.L. Oral anatom y, ed 5. St. Louis, C. V. Mosby Co., 1970, pp 448-465.
REPORTS
Soft tissue emphysema C . R o n a ld S p a u ld in g , D D S
A case of soft tissue emphysema as a complication of a routine dental restoration is presented. The causes, the differential diagnoses of hematoma, allergic reaction, inflammation and infection, and the management of emphysema are also discussed.
TJL issue emphysema refers to the
presence of air or gas in the soft tis sue.1 Many causes have been recog nized and reported and include fa cial,1,2 cervical, 1 and thoracic3 in jury, tracheostomy,1 and various procedures and conditions related to dentistry. Dental literature contains cases of particular interest because of the causes described. The causes can be the introduction of hydrogen peroxide into the soft tissues during endodontic therapy4 with the sub sequent release of free oxygen, forced free air from a dental syringe5 or air-driven turbine handpiece,6'7 self-induced emphysema after den tal extraction,8 or intraoral injury.9 Although the potential for soft tis sue emphysema during a surgical procedure is realized, the following case shows the existence of a similar potential during less invasive and seemingly more benign restorative dental procedures.
Report o f case During a routine restorative dental pro cedure, swelling was seen in the left in fraorbital region of a 17-year-old girl. The dentist sought immediate consultation. The dentist had adm inistered a local anesthetic about an hour before this in ci dent and had p roceeded w ith the restora tive treatment in the m axillary left quad rant. He said that access and visibility were lim ited in certain regions and that w ithin seconds o f drying on e area w ith the air syringe the sw elling w as noticed. W hen the patient was first seen, she seem ed to be extremely apprehensive but apparently healthy. Her m edical history
was essentially noncontributory, and she had n o k n ow led ge o f allergy to any m edications, in clu d in g local anesthetics. Examination show ed a large, soft sw elling w h ich extended from the left in fraorbital to the b u cca l region (Illustra tion). Other than the extreme anxiety n oticed initially, the patient had n o other sp ecific com plaints at that time. Skin rash, itching, other sw elling, or respira tory im pairm ents w ere not evident. The facial sw elling was nonpulsatile, and no bruit was heard w ith a stethoscope. In traoral exam ination disclosed a tem porarily restored m axillary left second m olar and a small (1-2 mm ) abrasion in the left buccal m ucosa.
JADA, V ol. 98, A p ril 1979 ■ 587
C L IN IC A L
REPORTS
Careful palpation o f the extraoral swelling disclosed fine crepitus throughout the region. Intraoral inspec tion at the time of extraoral palpation also showed several small bubbles exit ing from the mucosal abrasion. The diagnosis o f soft tissue em physema was made from these findings, and the portal of entry was assumed to be the buccal mucosal lesion. This assump tion was confirmed by blunt exploration through the wound into the cheek. The nature of this condition and palliative home-care measures (including anal gesics and moist heat applied to the re gion) were explained to the patient and her family. A seven-day regimen of prophylactic penicillin was begun, and the patient was discharged. When the patient was seen a week la ter, the swelling was completely resolved and the patient was asymptomatic. There was no evidence of crepitus in the af fected soft tissue and the mucosal injury noticed a week earlier was completely healed. The patient was discharged and has had no residual effect or recurrence.
Discussion T h e appearance of soft tissue em physem a d u rin g an otherw ise u n com plicated restorative procedure can be frig htenin g. T h e p atien t m ay in itia lly feel p ain or a sense of fu ll ness in the facial/cervical region and m ay even have d iffic u lty breath in g .4,7,10 R apid sw elling can fu rth er u nn erve p atien t and dentist. A d iffe ren tial diagnosis w ith the appearance of these signs could in clude hem atom a, allergic reaction, in fla m m a tio n and infection, as w e ll as em physem a. In flam m a to ry reac tio n or infection can be ru led out im m e d ia te ly because of the ra p id sw e llin g seen w ith em physem a. A ra p id ly occurring allergic reaction can m im ic em physem a durin g its early stages so patients m ust be ob served and treated should fu rth er signs o f allergic reaction such as p ru ritus, u rticaria, w heezing , or ra p id onset of cardiovascular col lapse occur. Perhaps the most d if fic u lt co n d itio n to ru le out w ith a ra p id sw e llin g w o u ld be hem atom a. T h e facial region is h ig h ly vascular so an inadverten t or unrecognized
588 ■ JADA, V ol. 98, A p ril 1979
accident w ith a sharp instrum ent co u ld result in a vascular in ju ry. A p ulsatile nature o f the sw e llin g or a b ru it heard w ith a stethoscope w o u ld suggest a hem orrhagic o rigin and ap p ropriate measures should be taken im m e d ia tely. T h e most useful sign in diagnosing em physem a is the crepitis. T h is feelin g o f m u ltip le gas bubbles or a crackling sensation w ith p alp a tio n is alm ost charac teristic of em physem a. F in a lly , radiographs can often show the air trapp ed in the soft tissue.5 O nce referred to as u n im p o rtan t or w ith o u t d an ger,11 the p o tential for serious sequelae is n o w recognized and should direct the m anagem ent o f em physem a. S im ultaneous in tro ductio n o f contam inated or septic m aterial u n d e r pressure can lead to in fe c tio n .1,12 L ocalized facial infec tions can become w idespread through fascial planes and potential spaces.13 Even in the absence of fra n k infection , the compressed air can spread th ro ug h the same ana to m ic routes w ith serious conse quences.10 Because of the p otential for infec tio n , treatm en t should be directed at pro ph ylactic m anagem ent. T h e p or tal of en try should be kept free of co n tam in ation and an tibio tic cover age should be in s titu ted im m ediately. T h e use o f m oist heat m ay be effective in increasing the vascular absorption o f free air though its p rim a ry advantage is probably as a placebo. F in a lly the p atien t m ust be w arn e d to avoid any intrao ral pressure— such as b lo w in g on a m usical instru m en t— w h ic h m ig h t introduce m ore air, or debris or both into the soft tissue. A d d ed discom fort can be con tro lled w ith analgesics i f needed. W ith o u t com plicatio n s the em physem a can be expected to resolve spontaneously in fiv e to seven days.
Sum mary M a n y cases of soft tissue em physem a have been reported; it is recognized as a com m on surgical and dental com plication. T his report
adds to the n um ber o f recorded cases and em phasizes the p otential for em physem a w ith the use of h ig h pressure dental instrum ents. I t also shows that the p o in t o f en try of a ir m ay be overlooked and w il l there fore delay diagnosis. Proper diagnosis and reco gn itio n o f the p o tential for w idespread sec ondary in fe ctio n dictate the m a n agem ent o f em physem a. I f any doubt should exist, consultation should be obtained w ith o u t hesitation.
Dr. Spaulding practices oral and m axillofacial surgery in St. Johnsbury, Vt. A ddress re quests for reprints to Dr. C. Ronald Spaulding, M edical Arts Building, Hospital Drive, St. Johnsbury, Vt 05819. 1. Irby, W.B. Current advances in oral surgery, vol 2. St. Louis, C. V. Mosby Co., 1977, pp 320-321. 2. Oswalt, T.G. Emphysema: case histories and conclusions. J M iss Dent Assoc 19:12-18, 1963. 3. Schwartz, S.I., and others, (eds.). Princi ples of surgery, ed 2, vol 1. New York, McGrawCo., p 660. 4. Bhet, K.S. Tissue em physem a caused by hydrogen peroxide. Oral Surg 38:304-307, 1974. 5. Poyton, H.G., and Arora, B.K. Radiologic evidence of surgical emphysem a. Report of a case. Oral Surg 35:129-131, 1973. 6. Segal, M., and Norton, H.D. Surgical em physem a occurring during conservative dental surgery. Dent Pract 17:274-276, 1967. 7. Hayduk, S.; Bennett, C.R.; and M onheim, L.M. Subcutaneous em physem a after operative dentistry: report of case. JADA 80(6):1362, 1970. 8. Shovelton, D.S. Surgical em physem a as a com plication of dental operations. Br Dent J 102:125-129, 1957. 9. Lee, J.L., Jr., and Bordenca, C.M. Self induced air em physem a of the face and neck. Oral Surg 36:603-605, 1973. 10. M arlette, R.N. M ediastinal em physem a follow ing tooth extraction: report of a case. Oral Surg 16:116-119, 1963. 11. Barber, J.W., and Bum s, J.B. Subcuta neous em physem a of the face and neck after dental restoration. JADA 75:167-169, 1967. 12. Kruger, Gustav O. Textbook of oral surgery, ed 4. St. Louis, C. V. Mosby Co., 1974, pp 183-184. 13. Sicher, H., and DuBrul, E.L. Oral anatom y, ed 5. St. Louis, C. V. Mosby Co., 1970, pp 448-465.
