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JAIN, SADHANA, GUPTA : SUBCUTANEOUS EMPHYSEMA FOLLOWING INTUBATION. 215
ASHOK\D:\JOBWORK\KOTUR\ANAESTH\ANAESTH3.P65215
LOCALISED SUBCUTANEOUS EMPHYSEMA
FOLLOWING INTUBATION-A CASE REPORT.Dr. Subodh Jain1 Dr. Sadhana Jain2 Dr. H. K. Gupta3
SUMMARY
Female patient aged 35 years planned for diagnostic laparoscopy developed localized sub-cutaneous emphysema of neck and cheek
above clavicle, 2 hour after intubation. The management of the same is hereby presented.
Keywords : Intubation, Extubation, Complications
Introduction
Intubation and extubation are the manoeuvres
commonly performed almost daily by all the
anaesthesiologists, but may be followed by acute and/or
chronic complications. Perforation of the mucosa with
passage of the endotracheal tube, into the soft tissues of
the neck may occur, leading to subcutaneous emphysema
and soft-tissue infection1. One such rare complication of
subcutaneous emphysema of neck and cheek is presented.
Case Report
A female patient, 35 years old, obese, weiging
65 kg was scheduled for diagnostic laparoscopy. Her pre
anaesthetic evaluation revealed nothing significant and was
as follows:
Pulse 88min -1; BP 110/70 mmHg; Hb
10.5gm%; BT = 2.03min; CT 3.40 min; urine albumin
and sugar Nil; CVS & RS NAD; No loose tooth.
Airway assessment was Malampatti grade I. 5% dextrose
infusion in the OR was started. Patient was premedicated
with Inj Atropine 0.6 mg followed by Inj Pentazocine
30mg, Inj Diazepam 5mg IV 5 min before induction.
Induction was carried out with Inj Thiopentone sodium
250 mg IV and Succinylcholine 100 mg IV followed by
IPPV with 100% O2. The patient was then intubated with
low volume, cuffed oral endotracheal tube no. 8 without
any difficulty. Tube was secured and cuff was inflated
with 5 ml of air till there was no leak around the tube.Anaesthesia was maintained with O2 and Halothane. Patient
was kept on spontaneous assisted ventilation using Magills
circuit.
With due aseptic precautions trochar was introduced
into peritoneum below umbilicus without any difficulty
and air was insufflated in peritoneal cavity at the rate of
2 L min-1 without any extravasation of air in abdominal
wall. The peak pressure in peritoneal cavity was 12-13
mmHg and the procedure lasted for about 30 min.
Patient was extubated at the conclusion of the
procedure and she made an uneventful recovery. No
difficulty was encountered during extubation. Patient was
shifted to anaesthesia recovery room, where the patients
condition was stable with P110 min-1, BP 110/86 mmHg.
SPO2 of 97% without O2 supplementation.
After about 150 min patient developed swelling in
neck and cheek below the ears and complained of
hoarseness of voice with stable signs. On examinationthere were crepitus on both sides of neck and cheek. No
crepitus was felt on chest, abdomen and back. Inj
Hydrocortisone 200mg IV and Inj. Dexamethasone 8mg
IV 8 hourly was given. The patient was kept under
observation.
Next day, direct laryngoscopy was done which
revealed congestion and redness at anterior commisure
and false vocal cords were normal. No other pathology
was seen. X-ray neck revealed air in subcutaneous tissues
of neck which confirmed the diagnosis of localized surgical
emphysema (Figure 1). No subcutaneous air was seen in
thorax region (Figure2).
Inj.Cefotaxime 1gm was administered to prevent
infection. On 2nd postoperative day swelling and crepitus
on cheek were reduced but crepitus persisted on right
side of the neck. On 3rd postoperative day the patient
made complete recovery and the patient was discharged
on 5th day.
Discussion
The literature search which we made did not yield
any report of localized subcutaneous emphysema of neck
1. Senior Registrar.
2. Associate Professor.
3. Prof. & Head.
Dept. of Anaesthesiology.
SP Medical College, Bikaner. Rajasthan.
Correspond to :
Dr. H. K. Gupta.
A1, PBM Campus, Bikaner, Rajasthan.
Indian J. Anaesth. 2002; 46 (3) : 215-216
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216 INDIAN JOURNAL OF ANAESTHESIA, JUNE 2002
and cheek following intubation. Hoarseness of voice
following general anaesthesia and intubation can occur
when large size tube with large cuff was used2. It was
hypothesized that smaller endotracheal tube with smallcuff, lower pressure on laryngeal interface and less surface
area for contact would reduce laryngeal damage and reduce
the incidence of sore throat and hoarseness of voice.
Swelling of the neck above clavicle and swelling of
cheek below ear could be due to air in subcutaneous tissue
which may enter from a breach in mucous membrane at
anterior commisure. Although the cause of this surgical
emphysema is not certain but it is attributed to be due to
injury at anterior commisure which was revealed later by
direct laryngoscopy by redness and congestion. Though
the intubation and extubation was without any difficulty,
this injury might have resulted from the tip of tube duringextubation. It was not related to insufflation of air in
peritoneal cavity.
The distensibility of sub-mucosal tissue of larynx
pa rti cu la rly su pr ag lo tti c po rt io n, pe rmit th e rap id
accumulation of fluid or blood; therefore laryngeal oedema
or haematoma typically involves the aryepiglottic fold.
The mucosal lining of larynx and pharynx is easily torn
by traumatic forces like intubation which may be followed
by rapid appearance of subcutaneous emphysema3.
In moderately severe injury because of elasticity of
laryngeal cartilage if the mucous membrane has been tornthere will be bleeding in airway and surgical emphysema
can occur. Gross haemoptysis and subcutaneous emphysema
may resolve completely without surgical intervention4.
There are multiple risk factors for developing
complications after intubation such as physical trauma
incurred during the act of intubation and is usually the
result of abnormal anatomy, difficult laryngoscopy, multiple
intubation attempts, and lack of skill of the operator.
Abnormal larynx is more prone to injury;
inflammation if already present makes the mucosa
more susceptible to pressure necrosis as in acute
laryngotracheobronchitis. Tracheomalacia is a congenital
disorder found in infant in which tracheal cartilage is very
weak, abnormal and is prone to injury.
Dark A et al described a case of severe post
operative laryngeal oedema causing total airway obstruction
immediately on extubation5.
So one should be very much aware of this
complication of subcutaneous emphysema of neck and
cheek, which is very rare following extubation.
References
1. Francis BQ, Christopher HR, Robert HS. Laryngeal injury as
a result of endotracheal intubation. Grand rounds presentation,
UTMB Dept of otolaryngology; May 1999, 1-10.
2. Michael Stoul, Micheal JB, jochen FD, Bruce FC. Correlation
of endotracheal tube size with sore-throat and hoarseness
following general anaesthesia. Anaesthesiology 67: 419-421,
1987.
3. John, Jacob, Ballenger. Trauma to larynx. In: Disease of nose
throat, ear head and neck. Chapter 29, 432-433.
4. Bryce DP, Trauma to Larynx. In: Disease of ear, nose and
throat. Vol 4; pp 331 333.
5. Dark A, Armstrong T. Case report severe postoperative
laryngeal oedema causing total air-way. Obstruction
after extubation British Journal of Anaesthesia 82 (4):
644 - 646, 1999.
CORRIGENDUM
1) Ref : ISA Gujarat Relief Fund. (List of Contributors as on 31-03-2001)
Indian J. Anaesth. 2001; 45(2):83
The name of Dr. Subhash G. of Hyderabad who donated Rs. 1000/-
was wrongly printed as Dr. Subhahinna. Mistake regretted.
2) Ref : Indian J. Anaesth 2002; 46 (2) : 83
The name of first author of the article titled Coronary Artery Bypass Surgery - A Case of
Terminal Renal Failure has wrongly been printed as Dr. Ashok Kumar in the contents
on page 83, instead of Dr. Anil Kumar. Mistake is regretted.