Subcutaneous emphysema and pneumomediastinum after tonsillectomy

doi:10.1016/j.amjoto.2009.02.004

American Journal of Otolaryngology

Volume 31, Issue 3, May–June 2010, Pages 212-215

https://doi.org/10.1016/j.amjoto.2009.02.004 Get rights and content

Abstract

Many patients and their families regard tonsillectomy as a minor operation because it is performed so commonly. However, although tonsillectomy is indeed a relatively safe surgical procedure, in extremely rare cases, it can be complicated by subcutaneous emphysema and pneumomediastinum. Although these complications resolve spontaneously in most cases, a few conclude in tension pneumothorax and other fatal complications. The mechanism by which subcutaneous emphysema and pneumomediastinum develop after tonsillectomy is poorly understood. We experienced a case in which subcutaneous emphysema, pneumomediastinum, and a deep defect in the tonsillar fossa were observed. The passage of air was shown by radiology and histopathology. Consequently, the case is reported here.

Introduction

Tonsillectomy is a frequently performed surgical procedure in the field of otolaryngology and is used to treat chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscess and various other conditions. Although tonsillectomy is a relatively safe surgical procedure, it is nevertheless associated with several complications, including bleeding, infection, lingual edema, injury of the glossopharyngeal nerve, and injury of the carotid artery [1]. In addition, the complications of subcutaneous emphysema and pneumomediastinum can also occur, albeit much more rarely. The latter complications were reported for the first time in 1953 and have since that time been reported only very infrequently [2]. Although the complications of cervical subcutaneous emphysema with pneumomediastinum after tonsillectomy reflect the inadvertent introduction of air, the passage of air to the mediastinum and subcutaneous tissues has rarely been observed directly. We experienced a case in which the passage of air was radiologically and histopathologically apparent. We report this case and also provide a literature review.

Section snippets

Case

A 36-year-old healthy woman who suffered frequently from tonsillitis was admitted for tonsillectomy. The preoperative physical examination revealed no other abnormalities. Tonsillectomy was performed under general anesthesia with orotracheal intubation. The tonsils were removed by monopolar electrodissection, and hemostasis was achieved by bipolar cautery. There was little bleeding, but the dissection was difficult because of the adhesion of the tonsils to the tonsillar bed.

On the first

Discussion

Subcutaneous emphysema can be a complication of a variety of oral and maxillofacial surgical procedures where mucosal integrity is breached. It has been reported that the development of subcutaneous emphysema in the oral cavity after surgery is caused by injury to the pharyngolaryngeal mucosa [3]. Although such injuries can be caused by surgical techniques, they can also arise from injury during intubation, excessive positive ventilation, and excessive manual ventilation [3], [4]. After the

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Cited by (23)

Subcutaneous emphysema with pneumomediastinum after elective tonsillectomy - Case study
2021, Otolaryngology Case Reports
Citation Excerpt :
Unilateral involvement supports the hypothesis of surgical cause [4,6]. Last but not least, except from dental or maxillofacial procedures, balloon Eustachian tuboplasty can also lead to cervicofacial and mediastinal emphysema [5,9,11,12]. As seen in our case and according to the results of various review studies [1,2,6,13] concerning the time of the onset of emphysema, in the majority of cases this occurred on the day of surgery.
Tonsillectomy is a common operation in otorhinolaryngology with subcutaneous emphysema with pneumomediastinum being an uncommon, nevertheless, potentially life-threatening complication. This case study reports the case of subcutaneous emphysema with pneumomediastinum following elective tonsillectomy and inferior turbinoplasty in a pediatric patient, along with the review of the relevant literature. Difficult dissection along with pressure increasing maneuvers seem to be the pathophysiologic mechanism in our case. Early detection and close monitoring are crucial. Usually the course is benign and self-resolving in a matter of days. Severe radiological appearance and worsening clinical symptomatogy may require surgical intervention. Turbinoplasty surgery seems to be irrelevant with the emergence of the complication.
Subcutaneous emphysema with pneumomediastinum after tonsillectomy: Case report and review of the literature
2020, International Journal of Pediatric Otorhinolaryngology
Subcutaneous emphysema is a rare complication of tonsillectomy.We report a case of post-tonsillectomy crepitus with radiographic extravasation of contrast from the tonsil fossa into the neck, subcutaneous emphysema, pneumomediastinum and small pneumothorax in a patient with Down Syndrome. Subsequent direct laryngoscopy showed no visible defect in the mucosal or muscle layers of the tonsil fossa. We explore common presenting symptoms, clinical course, and treatment of subcutaneous emphysema secondary to tonsillectomy.
Massive pneumomediastinum with subcutaneous emphysema after elective adenotonsillectomy in children: Involvement of the Boyle-Davis mouth gag
2019, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
It is considered relatively easy and safe, but the complication rate in healthy children can reach up to 8,3%, with hemorrhage being the main risk [1]. Other complications related to adenotonsillar surgery include odynophagia, otalgia, damage to teeth, infection, nausea and vomiting [2–7]. In addition, some rare, but potentially more serious complications of adenotonsillectomy are vascular or nerve injury, jugular vein thrombosis, Grisel syndrome, mediastinitis and cervicofacial subcutaneous emphysema (with or without pneumomediastinum) [5–9].
Adenotonsillectomy, a very common surgical procedure in otorhinolaryngology, is considered easy and safe surgery. However, clinicians should be aware of some less common but potentially life-threatening complications. This report discusses subcutaneous emphysema with pneumomediastinum following elective adenotonsillar surgery in children. The Boyle-Davis mouth gag seemed to play a part in the pathogenic mechanism of this rare complication in this case. Better insights in the mechanism of this severe complication of adenotonsillectomy may contribute to the prevention of this complication.
Late presentation of subcutaneous emphysema and pneumomediastinum following elective tonsillectomy
2015, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Citation Excerpt :
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.
Subcutaneous emphysema and pneumomediastinum are rare complications following 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.
Cervicofacial subcutaneous emphysema, a rare complication of tonsillectomy
2014, Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Citation Excerpt :
Tonsillectomy is a very common surgical procedure done by otolaryngologists for different indications, most commonly in cases of recurrent tonsillitis or tonsillar hypertrophy. It is considered a relatively safe procedure, with possible complications including hemorrhage, infection, teeth damage, otalgia, odynophagia, pharyngeal edema, and injury of the carotid artery.1,2 One of the very rare complications is subcutaneous emphysema.
Tonsillectomy is one of the most common surgical procedures performed worldwide, and because of that, it is regarded by surgeons and patients as a relatively safe procedure. One of the very rare complications post tonsillectomy is subcutaneous emphysema, as in our case here. Although most reported cases are resolved spontaneously, it may lead to potentially fatal complications, like tension pneumothorax. The mechanism for the development of subcutaneous emphysema is not well understood. We are reporting a rare case of healthy man, developed subcutaneous emphysema 4 days after tonsillectomy evident by clinical and radiological examination.
Safety implications of the Boyle-Davis mouth gag and tracheal tube position in tonsillectomy
2010, British Journal of Anaesthesia
Background. The risk of death after tonsillectomy is extremely small, and is mostly caused by the direct or indirect effects of haemorrhage or anaesthetic complications. These complications include aspiration, accidental dislodgement of the tracheal tube (TT), and pneumothorax or pneumomediastinum. The Boyle–Davis mouth gag (BDG) is a device used to visualize the oropharynx and stabilize the TT during tonsillectomy. We postulate that a deployed BDG may influence the position of the TT, and potentially result in silent aspiration, accidental extubation, and unilateral pulmonary ventilation. This has not, to our knowledge, been evaluated before. The aim of this prospective, pilot study was to evaluate the displacement of the TT upon opening and closing the BDG, in an objective manner.
Methods. Patients undergoing tonsillectomy with/without adenoidectomy at a regional department underwent flexible bronchoscopy to evaluate the changes in position of the TT tip with the BDG in an open and closed position, relative to the position of the carina.
Results. Twenty-three patients were enrolled into the study. Deploying the BDG resulted in TT displacement in 96% of patients. The mean displacement was 9.5 mm (range −10 to +27 mm).
Conclusions. We believe that this study raises concerns not previously highlighted, on how manipulating a BDG may influence the TT position. It may serve to explain additional mechanisms of potentially fatal anaesthetic complications such as TT dislodgement, unilateral ventilation, and pneumothorax, particularly in paediatric patients, after tonsillectomy.

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Case reportSubcutaneous emphysema and pneumomediastinum after tonsillectomy☆

Abstract

Introduction

Section snippets

Case

Discussion

Otolaryngol Head Neck Surg

Auris, Nasus, Larynx

Otolaryngol Head Neck Surg

Int J Pediatr Otorhinolaryngol

Braz J Otorhinolaryngol

Consent for tonsillectomy

Clin Otolaryngol Allied Sci

Subcutaneous emphysema following tonsillectomy and adenoidectomy

Minn Med

Case report
Subcutaneous emphysema and pneumomediastinum after tonsillectomy☆