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Print version ISSN 0034-7094
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.55 no.4 Campinas July/Aug. 2005
Subcutaneous emphysema after tonsillectomy. Case report*
Enfisema subcutáneo después de amigdalectomia. Relato del caso
Walter Luiz Ferreira Lima, TSA, M.D.I; Nivaldo Simões Correa, TSA, M.D.I; José Luiz de Campos, M.D.II; Paulo Moraes Navarro, M.D.II; Luciano de Oliveira Correia, M.D.III
ICo-Responsável pelo CET/SBA
do Hospital Vera Cruz
IIAnestesiologista do Hospital Vera Cruz
IIIME2 do CET/SBA do Hospital Vera Cruz
BACKGROUND AND OBJECTIVES: Tonsillectomy
is considered a relatively safe procedure. This report aimed at describing an
uncommon complication of this surgical procedure: subcutaneous emphysema.
CASE REPORT: Male patient, 25 years old, admitted for recurrent tonsillitis and hypertrophic nasal turbinates. Tonsillectomy and nasal cauterization were performed under general anesthesia with tracheal intubation. Surgery was uneventful. At post-anesthetic recovery unit (PACU), patient was agitated and performing major physical effort. Four hours after surgery, gross and crepitus swelling of neck and left parotid region, typical of subcutaneous emphysema, was noted. CT scan has revealed free air in the malar and cervical regions (especially to the left), reaching upper mediastinum. There was no airway obstruction and his general condition was stable. Patient was discharged one day after and was followed on ambulatory basis. Emphysema was no longer clinically evident 10 days after.
CONCLUSIONS: Subcutaneous emphysema is an uncommon complication of tonsillectomy, appearing almost ever after deeper dissections of the pharyngeal mucosa, when a porous surface is created, thus providing a route for the entry of air. Increased upper airway pressure may contribute to this injury.
Key Words: COMPLICATIONS: subcutaneous emphysema; SURGERY: tonsillectomy
JUSTIFICATIVA Y OBJETIVOS: La amigdalectomia
se considera como un procedimiento relativamente seguro. El objetivo de este
relato fue mostrar una complicación rara de esta cirugía, el enfisema
RELATO DEL CASO: Paciente del sexo masculino, 25 años, con amigdalitis recurrente e hipertrofia de cornetes. Fue sometido a amigdalectomia y turbinectomia bajo anestesia general con intubación orotraqueal. La operación transcurrió sin intercurrencias. En la sala de recuperación pos-anestésica (SRPA) el paciente se agitó, presentando grande esfuerzo físico. Cuatro horas después de la cirugía, se notó un edema crepitante y depresible en el cuello y en la región parotídea izquierda, característico de enfisema subcutáneo. La tomografía computadorizada mostró la existencia de aire en las regiones malar y cervical (principalmente a la izquierda), alcanzando hasta el mediastino superior. No hubo obstrucción de las vías aéreas y el estado general del paciente permaneció estable. Tuvo alta hospitalario en el día siguiente y fue acompañado en el ambulatorio. El enfisema retrocedió totalmente después de 10 días.
CONCLUSIONES: El enfisema subcutáneo es una complicación rara de la amigdalectomia, ocurriendo casi siempre después de disecciones profundas de la mucosa faríngea, cuando se crea interface porosa que proporciona la entrada del aire. El aumento de la presión en las vías aéreas superiores puede contribuir para el problema.
Tonsillectomy is one of the most common major surgical procedures highly prevalent in the pediatric population 1. Although being a relatively safe procedure, some tonsillectomy complications have been described 2-4, especially hemorrhage, in addition to others such as pain, fever, vomiting, dehydration, uvula edema, dental trauma, local infection, atlanto-axial subluxation, immune disorders, loss of vision and hypertensive crisis 2,4,5. This report aimed at describing a case of post-tonsillectomy subcutaneous emphysema.
Male patient, 25 years old, 70 kg, physical status ASA II, with recurrent tonsillitis, right peri-tonsillar abscess and inferior turbinates hypertrophy, who was submitted to tonsillectomy and nasal cauterization.
During preoperative evaluation, patient referred being under regular use of haloperidol to treat behavioral disorders mainly characterized by agitation. Physical evaluation was normal, good general state, relaxed, Mallampati II, in addition to normal laboratory tests. Patient was duly informed about the anesthetic-surgical procedure and was premedicated with oral midazolam (15 mg) 40 minutes before surgery, with satisfactory results.
Monitoring consisted of pulse oximetry, cardioscopy and noninvasive blood pressure. After left arm venoclysis, anesthesia was induced with fentanyl (250 µg), droperidol (5 mg), cisatracurium (14 mg), propofol (200 mg) and 5% lidocaine (100 mg). Laryngoscopy and tracheal intubation with 7.5 endotracheal tube (with cuff) was uneventful. Anesthesia was maintained with oxygen, nitrous oxide and sevoflurane.
Patient was ventilated with a positive pressure ventilator, pressure cycled (25 cmH2O) with 600 mL tidal volume. Surgery lasted 40 minutes with minor bleeding and without intercurrences. Patient was extubated in superficial anesthetic plane and a nº 3 Guedel airway was inserted in the oropharynx for oxygen therapy (3 L.min-1). Postoperative positive pressure ventilation was not needed.
At emergence, patient presented severe agitation, with major physical effort and had to be refrained to bed. Patient was discharged from PACU approximately one hour after this event. Four hours after surgery, patient presented gross and crepitus swelling of neck and left parotid region extending to left lateral cervical region. Patient was in good general state, eupneic, conscious and with stable vital signs, only complaining of tonsillar lodge pain.
Oral cavity evaluation and pulmonary auscultation were normal. Chest X-rays were normal and cervical CT scan revealed malar and cervical subcutaneous emphysema, especially to the left, in addition to air image dissecting cervical fascia and extending to upper mediastinum (Figure 1). There was also interruption of the air column in the left tonsillar lodge.
Patient was observed for the next 24 hours, fasting, and under prophylactic antibiotics. No cardiopulmonary changes were observed during this period and subcutaneous emphysema has progressively resolved, however incompletely. Ambulatory follow up was indicated after hospital discharge. Total resolution was seen 10 days after surgery.
Post-tonsillectomy subcutaneous emphysema is described in the medical literature, sometimes associated to pneumomediastinum 6-8, pneumothorax 3,6 and pneumoperitoneum, although being an uncommon complication of this surgery 3,9-11.
Traumatic intubation, local anesthetic infiltrations and deep tonsillar lodge dissection break pharyngeal mucosa integrity and may create a porous surface which helps the entry of air 3,6. Increased pharyngeal pressure caused by situations such as coughing, vomiting, physical effort, ventilation under excessive positive pressure, post-extubation manual ventilation and anesthetic circuit defects are decisive for the development of emphysema 3,6.
When the air enters the mucosa, it goes through upper pharyngeal constrictor muscle and easily dissects cervicofascial plans occupying parapharyngeal spaces. The anatomic connection between parapharyngeal and retropharyngeal spaces may promote upper airway obstruction 6,8,12. This is especially dangerous in young children, who have very fragile tracheal rings and may require emergency tracheostomy 9.
When large volumes of air progressively enter, there is the possibility of pneumomediastinum and even cardiac tamponade 11. Dyspnea, dysfagia, chest pain, cyanosis and skin crepitation synchronized with cardiac systole (Hamman's sign) indicate pneumomediastinum 9.
Pneumothorax and pneumoperitoneum caused by air entry in the abdominal cavity via diaphragm orifices 1,3 may limit respiratory function and worsen symptoms.
Crepitation and depression at palpation, in addition to radiological findings, confirm subcutaneous emphysema, and CT scan is the most recommended additional test 3.
The evolution of subcutaneous emphysema secondary to tonsillectomy is usually benign and self-limited 3. Treatment is conservative because, in general, process is spontaneously resolved 3,9. Strict observation of cardiopulmonary function and progression of emphysema is critical 3. Attitudes which may worsen the problem should be avoided, such as activities increasing airway pressure (coughing, vomiting, physical effort, etc.) 3,9. Broad spectrum antibiotics are indicated to prevent infection 3,6,8,9, as well as feeding restriction 9. Whenever possible, pharyngeal mucosa should be sutured to prevent emphysema progression and the entry of opportunistic bacteria 9.
In our case, it is possible that the loss of pharyngeal mucosa integrity secondary to tonsils dissection, associated to physical effort during postoperative recovery, were the major causes of the complication.
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Dr. Walter Luiz Ferreira Lima
Address: Av. Andrade Neves, 402 Botafogo
ZIP: 13013-900 City: Campinas, Brazil
Submitted for publication December 2, 2004
Accepted for publication April 4, 2005
* Received from CET/SBA do Hospital Vera Cruz, Campinas, SP