Iatrogenic pneumomediastinum with extensive subcutaneous emphysema after endodontic treatment: report of 2 cases

Pronounced mediastinal emphysema after restorative treatment of the lower left molar-a case report and a systematic review of the literature

This case report presents an iatrogenic induced mediastinal emphysema after restorative treatment of the lower left second molar, aimed to highlight the potential life-threatening consequences, and providing diagnostics and treatment concepts of complicated dental induced emphysema based on literature review. A 74-year-old female patient was admitted to the emergency department due to a fall on her shoulder. Additional finding was a significant swelling of the face and neck. In the computer tomography of the head, neck, and thorax, a humerus fracture and pronounced soft tissue emphysema from the infraorbital region to the mediastinum was detected. The patient reported that she had been treated by her dentist 4 days earlier. The treatment had to be discontinued after beginning of a pronounced swelling. Other reasons for the emphysema could be excluded out on an interdisciplinary teamwork. The patient was monitored as an inpatient for 5 days and received intravenous antibiotic therapy. This case report shows the rare complication of pronounced mediastinal emphysema after root canal treatment. Emphysema should always be a differential diagnosis of soft tissue swelling and, in case of doubt, a general medical presentation should be made.

Causes of subcutaneous emphysema following dental procedures: a systematic review of cases 1993-2020

Objectives Causes of subcutaneous emphysema (SE) following dental treatment have changed with new operative techniques and equipment. This review demonstrates the frequency and aetiology of SE to inform prevention strategies for reducing SE occurrences.Methods A systematic search of Medline, Embase and PubMed databases identified 135 cases of SE which met inclusion criteria after independent review by two authors. Trends in frequency and causes of SE were displayed graphically and significant differences in frequency of SE by time period, site and hospital stay were analysed using t-tests.Results Dental extractions often preceded development of SE (54% of cases), commonly surgical extractions. Treatment of posterior mandibular teeth most often resulted in development of SE. Most cases were iatrogenic, with 51% resulting from an air-driven handpiece and 9% from air syringes. Factors such as nose blowing accounted for 10%. There was a significant (p <0.05) increase in cases over time. Mandibular teeth had increased hospital stay time compared to maxillary teeth (p <0.01).Conclusion Increased risks of SE were identified following use of air-driven handpieces during dental extractions and when treating lower molar teeth. Use of air-driven handpieces should be avoided during dental extractions to reduce risks and subsequent morbidity that results from SE.

Cervicofacial and mediastinal emphysema following minor dental procedure: a case report and review of the literature

Background

Subcutaneous cervical emphysema is a clinical sign associated with many conditions, including laryngotracheal trauma, pneumothorax and necrotizing deep tissue infections.

Case presentation

We discuss a case of a 76-year-old man presenting with extensive cervical emphysema a few hours after a minor dental filling procedure. The CT-scan revealed a significant amount of air within the cervical and mediastinal spaces, reaching lobar bronchi. Vitals were within normal values Bloodwork demonstrated an elevation of creatinine kinase (3718; normal < 150) and mild leukocytosis (WBC = 11.6). We decided to proceed to an urgent cervical exploration to exclude necrotizing fasciitis. This revealed air but no tissue necrosis nor abnormal fluid. The patient improved clinically and was discharged two days later with oral antibiotics. Although cervicofacial subcutaneous emphysema following dental procedures has been reported, it is usually less extensive and involving more invasive procedures using air-driven handpieces.

Conclusion

As an otolaryngologist confronted with extensive subcutaneous emphysema following a potential entry route for an aggressive infection, given the seriousness of this diagnosis, the decision of whether or not to perform a diagnostic surgical exploration should remain.

Complication of tracheotomy: A case of fatal pneumomediastinum in spontaneous ventilation

Pneumomediastinum is defined as the presence of free air in the mediastinal space. It is classically defined as either spontaneous or secondary pneumomediastinum, depending on whether a cause can be recognised (e.g. trauma, intrathoracic infections or medical procedures such as dental or facial surgery and tracheotomy). It can be associated with pneumothorax and subcutaneous emphysema of the cervico-facial area because of the ascent of the air from the mediastinum towards the neck. To our knowledge, only one case of death from pneumomediastinum due to tracheotomy has previously been recorded. We report a case of death due to pneumomediastinum, which occurred in a patient with a tracheotomy during spontaneous ventilation. The 65-year-old man underwent surgical mandibular reconstruction with a custom-made titanium plate for osteonecrosis with temporary tracheotomy. The patient received mechanical ventilation only during surgery. On day 3, when the tracheotomy was closed, the patient experienced a rapid deterioration of lung ventilation with initial development of subcutaneous cervical emphysema. Although a tracheotomy tube was promptly inserted, the patient developed massive subcutaneous cervico-facial emphysema with a drop in oxygen capillary saturation. The man died after half an hour of resuscitation due to a massive pneumomediastinum. In this paper, we discuss the epidemiology, aetiology, physiopathology, complications and necropsy findings in pneumomediastinum, focusing on the aspects of our case compared to the only other case reported.

Cervicofacial subcutaneous emphysema and pneumomediastinum secondary to dental treatment in a young man

The occurrence of cervicofacial subcutaneous emphysema and pneumomediastinum is very rare but can be potentially life-threatening.

These complications can happen during or after bronchoscopic or dental procedures, esophageal rupture or perforation, infections involving the head and neck and alveolar rupture in the setting of an inciting event such as asthma. The symptoms can appear promptly after the inciting event, but can also be delayed or do not reach maximal intensity for hours.

Cervicofacial subcutaneous emphysema usually occurs during or within minutes to hours after dental treatment and can be easily misdiagnosed as post-procedure swelling or an allergic reaction.

We report a 36-year-old male who underwent dental treatment for a fractured left lower molar tooth and subsequently developed extensive subcutaneous emphysema and pneumomediastinum. The purpose of this report is to bring attention to the fact that obtaining an accurate diagnosis for this condition is very important and management in a timely manner can prevent serious complications.

Risk Factor in Endodontic Treatment: Topographic Evaluation of Mandibular Posterior Teeth and Lingual Cortical Plate Using Cone Beam Computed Tomography (CT)

Background

Topographic relationships of mandibular posterior teeth with mandibular cortical plate are extremely important both in terms of infection spread and endodontic and surgical procedures to be performed. The aim of this study was to determine the relationship between root apex of the mandibular posterior teeth and lingual plate of the mandible.

Material/Methods

CBCT data of 138 patients were retrospectively analyzed. The topographic relationship between root apex and lingual plate was classified as non-contact, contact, or perforation. Morphology of the mandibular lingual plate was classified into the 4 types (convex, parallel, undercut, slanted) and recorded for each tooth region. The prevalence of each group was calculated.

Results

In 6.2% of all mandibular posterior teeth, the lingual plate was perforated by at least 1 root of the corresponding tooth. The teeth with the highest perforation rate were the third molar tooth (31.6%) and the second molar tooth (14.7%). The most common mandibular lingual plate morphology type was “undercut type” (61.3%) in the molar teeth region, while “parallel type” (55.7%) was most common in the premolar teeth region.

Conclusions

In conclusion, a high percentage of mandibular second and third molars root apex have topographically close relationships to the lingual plate of the mandible. Hence, endodontic consultants must be aware by this anatomical relationship and be aware of possible complications during endodontic and surgical procedures using radiographical modalities.

Iatrogenic subcutaneous facial emphysema secondary to a Class V dental restoration: a case report

Subcutaneous facial emphysema (SFE) following routine dental operative procedure is an uncommon but potentially life-threatening complication. The present case details a Class V restoration where air was introduced into the fascial tissue planes via the gingival sulcus from the use of an air-driven dental handpiece. Although the SFE is usually self-limiting within 3-10 days, such instances should be regarded as a medical emergency as in severe cases, the air may spread to the neck, mediastinum and thorax to result in cervicofacial emphysema with potential pneumomediastinum and pneumothorax.

Massive Cervicothoracic Subcutaneous Emphysema and Pneumomediastinum Developing during a Dental Hygiene Procedure

Subcutaneous emphysema is rare during or after dental procedures (usually extractions). Here, we describe the case of a 65-year-old woman who developed massive cervicothoracic subcutaneous emphysema and pneumomediastinum during a dental hygiene procedure employing an artificial airflow. She was diagnosed based on clinical manifestations and computed tomography (CT). CT revealed massive subcutaneous emphysema extending from the superior left eyelid to the diaphragm. We describe the clinical and radiological characteristics of this rare case.

Orbital and Periorbital Emphysema Following Maxillary Sinus Floor Elevation: A Case Report and Literature Review

During the past 150 years, subcutaneous emphysema has been described as a rare complication in dentistry, the etiology of which might be maneuvers performed by the patient (eg, sneezing while the mouth is closed, blowing the nose) or the dental professional through the use of specific dental instruments (eg, dental drill, air syringe, etc). Irrespective of etiology, air is forced through the soft tissues, thus producing rapid swelling of the area. According to the most recent literature reviews, the iatrogenic etiology is the most frequent. This report describes the first case of emphysema related to the orbital and periorbital region after a maxillary sinus floor elevation procedure.

Occurrence of pneumomediastinum due to dental procedures

The occurrence of pneumomediastinum and massive subcutaneous emphysema due to dental procedures is quite rare. We present a case of pneumomediastinum and massive subcutaneous emphysema that occurred during third molar tooth extraction with air-turbine handpiece.

Iatrogenic subcutaneous emphysema of endodontic origin - case report with literature review

Surgical emphysema is well known and many case reports have been published on this. Many authors have reported this as a complication post dentoalveolar treatment. Diffusion of air into facial planes and periorbital area during endodontic procedures has been rarely reported. The use of three way air syringe and forceful irrigation of root canal can lead to surgical emphysema of subcutaneous tissue planes in and around the teeth which are involved. This case report highlights one such complication seen during endodontic treatment, discusses aetiology, complications and conservative management of this dental office emergency.

Orbital, mediastinal, and cervicofacial subcutaneous emphysema after endodontic retreatment of a mandibular premolar: a case report

INTRODUCTION

Subcutaneous emphysema (SCE) rarely occurs from endodontic treatment. Most reported cases of iatrogenic SCE occur in the cervicofacial region. Only a few cases have been reported of SCE extending into the mediastinum or orbital spaces. In the present report, we describe a concomitant occurrence of orbital, mediastinal, and cervicofacial SCE immediately after endodontic retreatment.

METHODS

A 33-year-old woman presented to the hospital with acute swelling of the right side of her face and neck. Earlier in the day, she began experiencing rapid swelling while undergoing endodontic retreatment of a mandibular right first premolar by her general dentist. The dentist immediately referred the case to an oral surgeon who then ordered additional tests and radiographic studies at the hospital. From there, the patient received consultation and comprehensive treatment by a multidisciplinary team of medical and dental staff.

RESULTS

Physical examination, laboratory tests, and computed tomographic studies confirmed a diagnosis of SCE. Extensive air pockets were detected within the orbital, mediastinum, and cervicofacial spaces. The patient was admitted to the hospital and underwent treatment and observation for massive SCE with likely secondary infection. On the fifth day, she was discharged after showing dramatic improvement.

CONCLUSIONS

SCE may go undetected or misdiagnosed. Complications may be fatal. Therefore, clinicians should apply preventive measures and know how to identify and manage SCE. We review reports of SCE in the last century, discuss etiology and differential diagnosis, and present recommendations for prevention and management of SCE.

Cervicofacial emphysema and pneumomediastinum after a high-speed air drill endodontic treatment procedure

Cervicofacial subcutaneous emphysema is defined as the abnormal introduction of air in the subcutaneous tissues of the head and neck. It is mainly caused by trauma, head and neck surgery, general anesthesia, and coughing or habitual performance of Valsalva maneuver. The occurrence of subcutaneous emphysema after dental treatment is rare, and diffusion of gas into the mediastinum is much rarer, especially when the procedure is a nonsurgical treatment. The most common dental cause of pneumomediastinum is the introduction of air via the air turbine handpiece during surgical extraction of an impacted tooth. Only 6 cases of pneumomediastinum after endodontic treatment have been reported between 1960 and 2008. Pneumothorax is defined clinically as an “accumulation of air or gas between the parietal and visceral pleurae,” and although it is often not a medical emergency, it can result in respiratory distress, tension pneumothorax, shock, circulatory collapse, and even death. Although there are many possible causes of dyspnea during a dental procedure, 1 rare complication is pneumothorax. Although specific closed turbine systems are available for oral surgical procedures, these drills may be used in exodontia to section teeth and facilitate tooth extraction. We report a case of cervical subcutaneous emphysema and pneumomediastinum occurring after an endodontic treatment of right first molar using an air-tribune drill. We present here in a case of massive pneumomediastinum and cervicofacial subcutaneous emphysema that occurred after opening the access cavity for endodontic treatment. We describe its etiologies and guidelines for its prevention during nonsurgical endodontic treatment.

Subcutaneous emphysema during third molar surgery: a case report

Extraction of third molars is the most common surgical procedure performed in oral surgery on a daily basis and, despite surgical skills and expertise, complications may occur. Complications observed during or after third molar removal may include pain, swelling, bleeding, infection, sinus perforation and nerve damage. Fortunately, with a proper management and a good surgical technique, the incidence of such events is low. Subcutaneous emphysema associated with dental extraction occurs when the air from the high-speed dental handpiece is forced into the soft tissue through the reflected flap and invades the adjacent tissues, leading to swelling, crepitus on palpation and occasionally spreading through the tissue spaces of the fascial planes. Although rare, iatrogenic subcutaneous emphysema can have serious and potentially life-threatening consequences. Care should be taken when using air-driven handpieces. The access of air into the facial tissues is not limited to tooth extractions, but may also occur through other portals of entrance, such as endodontically treated teeth, periodontium and lacerations of intraoral soft tissues. When subcutaneous emphysema occurs, it must be quickly diagnosed and properly managed to reduce the risk of further complications. This report presents a case of subcutaneous emphysema occurred during extraction of a mandibular third molar extraction with the use of an air turbine handpiece. Case management is described and issues relative to the diagnosis and prevention of this surgical complication are discussed.