Very cool (and odd ) case

[med2UCC]

I had a weird one tonight and just had to share. I got a call from one of the local dentists regarding a patient he said he had given an air embolus to while doing a routine filling. Fortunately he was wrong - he'd only given her subcutaneous emphysema from the thoracic outlet to the inferior orbit on the left. I wish I could figure out how to attach the CT-very cool pics. She had quite apparent swelling on that side and palpable subcutaneous emphysema. Fortunately she had neither pneumothorax nor pneumomediastinum (nor, for that matter, pneumocranium, also a complication of dentistry).
Needless to say, I wasn't really sure what to do with her. Eventually the consensus was observe for 12 hours, abx to cover any infection and FU in 2 days to make sure the emphysema is resolving (but no hints on what to do if it isn't).
Anyone else run into this? If so, what did you do/ Cheers,
M
who worked 3 hours overtime tonight and has to be on deck in 5 hours (ugh!)

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[deleted109597]

Uh, how? Did he switch from suck to blow?

 

[8654Marine]

I remember some cases like this during my residency.

As long as there is no PTX, mediastinal air, or air embolism and if the air is strictly subQ, observe.

The patients that I had were post op patients, n=3, and observed, no complications.

We looked at some literature (this was in the 90's) about skin poking (blow holes), but was not convinced and did not do it.

N=3 patients recovered without sequela.

 

[med2UCC]

Uh, how? Did he switch from suck to blow?

He's not sure, but he was pretty freaked out about the whole thing. Apparently this is a very rare complication of dental surgery but unknown from a simple filling. This will be qritten up as a case report, of course. Cheers,
M

 

[Birdstrike]

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[med2UCC]

You didn't say whether this was from an upper tooth or lower. Guess what, I already know: upper.

Subcutaneous emphysema, by itself, is irrelevant (unless it's massive, and restricting chest wall movement, or something mechanically). What you need to be sure of is what caused it.

In this case, likely there was a communication to the maxillary sinus from drilling an upper tooth and poking through the wall of the sinus. So basically, you have an open fracture of the sinus. The concern would be infection. You want her to see ENT. Likely they'd do nothing but follow her and put her on antibiotics.

Actually, she had a CT of the facial bones and soft tissues as well as the neck. The procedure was a filling in a lower molar. The CT showed no fractures and nothing odd except the subcutaneous air. I consulted ENT locally and at our provincial referral centre, and neither were interested in following her up so we held her overnight, sent her home with abx and did serial exams on 2 subsequent days with serial chest x-rays as well. Her initial chest x-ray was negative and her repeat films were the same. The swelling is coming down and so far she has no signs of infection. The dentist is also doing well. Cheers,
M

 

[Birdstrike]

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[pinipig523]

I just read about this a few days ago - it's been well documented that you can get subq air with dental procedures. You really don't do anything but observe.

 

[turkeyjerky]

I just read about this a few days ago - it's been well documented that you can get subq air with dental procedures. You really don't do anything but observe.

Are ABX required?

 

[med2UCC]

Both the ENT's I called suggested ABX. The concern was that along with the air she might also have saliva subcutaneously, which makes sense since the air came in through her jaw. Cheers,
M