SUBCUTANEOUS

EMPHYSEMA

INTRODUCTION

Emphysema - Greek word, ‘whick’ - ‘to blow in.’

Subcutaneous emphysema of the head,neck, and thorax is caused by the introduction of air into the fascial planes of the connective tissue.

Because of the looseness of the connective tissue and its distensible walls, air can accumulate in these crevices and convert them into spaces of considerable size.

Periorbital emphysema is

subcutaneous emphysema that arises

when air is introduced into the

periorbital tissues.

Subcutaneous emphysema arises

when air is forced, under pressure, into

the subcutaneous fascia leading to a

sudden

onset of soft tissue swelling

compressed air {air syringe}

patent canal

periapical tissue

labial cortical plate,

periorbital space. Periorbital space - low tissue resistance air accumulates readily in this space -

sudden onset of the swelling of upper and lower eyelids.

Pressurised air

labial sinus tract gingival sulcus

periorbital emphysema

CAUSES

During apical surgery, air from a high-

speed drill can lead to air emphysema.

Blowing the nose vigorously

Habitual performance of Valsalva

manoeuvre

Playing a wind instrument after an

extraction

Trauma

Vigorous coughing

Surgical procedures during which air is

introduced into soft tissue spaces.

Endodontic origin occur following the

use of air-driven handpieces,

use of H2O2 irrigation

use of air syringe to dry the canal

Any time a stream of air is directed

toward exposed soft tissues, the

potential for a problem exists.

Signs & symptoms

Immediate

Local soft skin-

coloured swelling

without redness

Crepitus

Local discomfort

Subsequent

Diffuse swelling

Local erythema

Pyrexia and Pain

Hayduk et al. regard crepitus as

pathognomonic of tissue space emphysema

which allows one to quickly rule out

anaphylactic reaction.

Dysphagia

Dyspnea: Migration of air into the neck region

could cause respiratory difficulty, and

progression into the mediastinum could

cause death.

Pain is a variable feature of

subcutaneous emphysema and

patients usually complain of

discomfort due to soft tissue

distension.

Unlike irrigant extrusion reactions,

tissue space emphysema remains in

the subcutaneous connective tissue

and usually does not spread to the

deep anatomic spaces

Alarming to the patient and clinician.

Rarely,serious complications such as pneumomediastinum and airway compromise are seen.

On rare occasions trapped air can spread along the fascial planes to the periorbital, mediastinal,parapharyngeal, pericardial and thoracic spaces causing serious and life threatening complications.

Its occurrence in conjunction with

a dental procedure was first reported

more

than a hundred years ago when Turnbull

extracted the premolar of a musician who

blew his bugle immediately after

extraction.

MANAGEMENT

Usually a benign condition that

resolves over 3–10 days as the gas is

resorbed into the blood stream for

eventual excretion via the lungs

Supportive management

Most authors, however, recommend a

course of prophylactic antibiotics,

most commonly penicillin and

analgesics for 10 days to prevent

secondary infection from

dissemination of oral flora along the

emphysematous tract

Cough suppressants may be

prescribed to prevent further air entry

into the fascial planes

A follow-up appointment within 48

hours is imperative to monitor

resolution and signs of infection

Severe cases, hospitalization may be

necessary for observation and follow-

up radiographs

Administration of 100% oxygen via a

non breather mask can hasten the

resolution of emphysema because

oxygen, which replaces the air, is more

readily absorbed.

Nitrous oxide sedation: the

administration of nitrous oxide should

be discontinued because the gas will

diffuse into the air spaces and increase

the volume of trapped air.

PREVENTION

Avoiding the use of direct

compressed air to dry root canals.

Using remote exhaust handpieces or

electric motor driven ones.

Avoiding the use of hydrogen

peroxide as a root canal irrigant.

Using sterile cotton pellets and

endodontic paper points to dry root

canals.

In surgical procedures, once a flap is

reflected, apical access can be made

with the slowspeed or high-speed

handpieces that do not direct jets of

air into surgery sites

If the air syringe is to be used, Jerome

suggested horizontal positioning over

the access opening, to aid in drying

the canal.

CONCLUSION

Subcutaneous emphysema is a rare but potentially serious complication of root canal treatment.

Characterised by sudden onset of soft tissue swelling, associated with crepitus, during or shortly after the procedure.

Introduction of compressed air into tissue spaces via patent canals, sinus tracts, soft tissue lacerations, or gingival sulcus is the underlying mechanism in most cases.

Therefore, blowing compressed air

into root canals should be avoided and

paper points should be used to dry

root canals.

The majority of cases are managed

conservatively and patients should be

advised as to the nature of

emphysema

REFERENCES

A. Al-Qudah, F. Amin and Y. Hassona.

Periorbital emphysema during

endodontic retreatment of an upper

central incisor:a case report:British

Dental Journal nov 9 2013; 215(9)

Dr. Abdul Hameed.Periorbital

emphysema unexpected

complication;Your Guide on the path

of Dentistry.

Rakesh K. Yadav ,Anil Chandra ,A. P.

Tikku, K. K.Wadhwani,Promila verma;

Air emphysema - an in office

emergency: A case report.

Lora Mishra, Swarnav Patnaik,

Sangram Patro, Nitai Debnath,

Satyaranjan Mishra. Iatrogenic

Subcutaneous Emphysema of

Endodontic Origin – Case Report with

Literature Review. Journal of Clinical

and Diagnostic Research. 2014 Jan,

8(1): 279-281

Manon Paquette. Subcutaneous Emphysema; Clinical Images in Oral Medicine and Maxillofacial Radiology