Spontaneous subcutaneous emphysema

Spontaneous Subcutaneous Emphysema ROBERT L. HOPKINS, MD,* MERLIN HAMRE, MD, MPHJ SCOTT H. DAVIS, MD,* STANLEY L. BONIS, MD,+ EDWIN M. FRIEBERG, MD* Subcutaneous emphysema is an unusual compitcation of bronchioiitis. The investigators describe a patient with bronchioiitis who developed extensive subcutaneous emphysema. Despite an alarming appearance, the patient recovered with symptomatic care and obsenfation. Review of the literature shows a multitude of causes of subcutaneous emphysema. The vast majority of cases resolve without intenention. (Am J Emerg Med 1994;12:463-466. Copyright 0 1994 by W.B. Saunders Company) Subcutaneous emphysema or aerodermectasia is a complication of trauma, surgery, assisted ventilation, medical or dental procedures, and many diseases (Table 1). Spontaneous subcutaneous emphysema results from causes that are

neither iatrogenic or related to trauma. The clinical manifestations of subcutaneous emphysema include a puffy and bloated appearance that may extend from the top of the head to the upper arms and thighs. This swelling is crepitant to palpation.’ The following is a case report of spontaneous subcutaneous emphysema associated with bronchiolitis and a review of the literature concerning the etiology and clinical presentations of spontaneous subcutaneous emphysema. CASE REPORT J.M. is a 14-month-old white male who was in good health until he had subjective fever. emesis, nonproductive cough, and diarrhea. He was seen that day by a family physician, and diagnosed as having otitis media. He was treated with cefaclor and the fever defervested. However, after a few days. his fever recurred along with wheezing, cough, and nasal congestion. He was then seen by another physician, 5 days after his first visit, who admitted him to the hospital with diagnoses of otitis media and bronchiolitis. Physical examination showed an immobile, inflamed right tympanic membrane, nasal congestion, and bilateral expiratory wheezing. His temperature was 38.4”C, and his chest roentgenogram showed perihiiar infiltrates with mild overinflation. He was given erythromycin ethylsuccinate and suitisoxazoie acetyl and acetaminophen. Two days after hospitalization the patient began having high fever and increasing respiratory difficulty. An arterial blood gas (Fio, = 21) showed pH 7.42, Pco, 35 mm Hg, and PO, 73 mm Hg. lntravenous fluids, ampicillin, aerosolized metaproterenol, and oxygen therapy were begun. An intravenous aminophylline drip and hydro-

cortisone were begun the next day because of persistent hypoxemia. From the Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA; tDepartment of Pediatrics, Northwestern University School of Medicine, Chicago, IL; and the *Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, LA. Manuscript received November 30, 1993; revision accepted February 2, 1994. Address reprint requests to Dr Robert L. Hopkins, Department of Pediatrics, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans. LA 70112. Key Words: Barotrauma, bronchiolitis, children, pediatrics, subcutaneous emphysema. Copyright 0 1994 by W.B. Saunders Company. 0735-6757/94/l 204-0018$5.00/O

Five days after initial hospitalization, he was transferred to a second hospital because of continuing respiratory distress and crepitant swelling of the neck and left side of the face. This swelling progressed to involve the left periorbital area, back, chest, abdomen, and scrotum (Figure 1). A chest roentgenogram confirmed subcutaneous emphysema without evidence of pneumothorax or pneumomediastinum (Figure 2). The next day he was transferred to the Pediatric Intensive Care Unit at Tulane University Hospital (New Orleans, LA). Admission examination showed a temperature of 37.X. pulse of 156 beats/min and a respiratory rate of 58 breaths/min. The patient displayed bilateral crepitant periorbitai swelling and continued evidence of otitis media. His neck showed massive crepitant distension. Chest auscultation showed diffuse-end expiratory wheezes. The abdomen appeared distended with no organomegaiy. The scrotum was grossly distended and displayed two testes when transiiluminated. Examination of the skin showed puffiness and crepitus over the entire body except for the buttocks and lower extremities. The patient was given intravenous fluids, oxygen (Fio, = 0.4). and intravenous cefuroxime. Bronchodilators included aminophylline and aerosolized metaproterenol. A posterior-anterior and lateral chest roentgenogram showed diffuse subcutaneous emphysema and marked hyperaeration of the lungs. Fluorescent antibody studies on nasopharyngeai washings were positive for respiratory syncytial virus. Sweat chloride concentration was normal. Cefuroxime was stopped after 96 hours. The patient’s subcutaneous emphysema and respiratory distress gradually resolved, and he was discharged home 5 days after being transferred to Tulane Medical Center.

SUBJECT REVIEW Subcutaneous

emphysema

may arise from

four potential

sources: (1) a break in the continuity of the respiratory tract; (2) a rent in the gastrointestinal tract; (3) atmospheric or intra-abdominal air entering the subcutaneous tissues through a break in the skin, genitourinary tract, or peritoneum; and (4) gas-forming infections. Mechanisms for the development of pneumomediastinum, pneumothorax, and subcutaneous emphysema from a break in the continuity of the respiratory tract were described by Macklin and Macklin.’ They proposed that pulmonary interstitial emphysema resulted from disruption of pulmonary alveoli because of increased transpulmonary pressure. Free air from the disrupted alveoli would then dissect along bronchovascular sheaths causing a pneumomediastinum from which air could then pass along fascial planes to cause subcutaneous emphysema and pneumoperitoneum. Free air could also pass into the pleural space, causing a pneumothorax. Subcutaneous emphysema may be the initial clinical manifestation of a pulmonary air leak because of air escaping a pneumomediastinum before radiological evaluation3 or as a consequence of only obtaining an anterior-posterior chest roentgenogram because only 50% of pneumomediastinums will be detected if a lateral chest roentgenogram is not obtained.4 463

AMERICAN

464

TABLE 1. Conditions

Associated

JOURNAL

OF EMERGENCY

MEDICINE

n

Volume

12, Number

4

n

July

1994

With Subcutaneous

Emphysema Pulmonary conditions Asthma Stevens-Johnson syndrome Measles Pneumonia Influenza Acute obstructive laryngitis Diphtheria Smallpox Tuberculosis Gastrointestinal conditions Esophageal rupture Weight lifting Blunt abdominal trauma Perforated peptic ulcer Rectal trauma Inflammatory bowel disease Gas-forming organisms Clostridia Anaerobic Streptococci Coliforms Others Factitious subcutaneous emphysema (self-inflicted injury)

Silicosis Foreign body aspiration Screaming Cocaine freebasing Diabetic ketoacidosis Seizures Labor Mechanical ventilation

Intestinal obstruction Diverticulitis Appendicitis Colon cancer Anal fistula

Hemolytic Staphylococci and Streptococci

Trauma Surgery Dental procedures

Clinical conditions that may predispose a patient to develop pneumomediastinum and subcutaneous emphysema include acute bronchial asthma.5,” Stevens-Johnson Syndrome,’ measles,’ pneumonia, influenza, acute obstructive

FIGURE 1. Patient with widespread subcutaneous emphysema involving face, trunk, upper extremities, and scrotum.

FIGURE 2. Posterior-anterior chest roentgenogram of case no. 1 illustrating hyperinflation. pneumomediastinum. and subcutaneous emphysema.

laryngitis, diphtheria, small pox, tuberculosis, silicosis, aspiration of a foreign body,’ yelling or screaming,3 and, as described in this case. bronchiolitis. Alveolar overinflation and rupture may also be created by a Valsalva maneuver. This pressure gradient helps to explain development of subcutaneous emphysema during the second stage of labor. resulting in Hamman’s syndrome.’ The same mechanism for developing pneumomediastinum and subcutaneous emphysema may be associated with diabetic ketoacidosis because of the hyperemesis, hyperpnea, and grunting respirations. ‘” Overby and Litt’ ’ described mediastinal emphysema and subcutaneous emphysema associated with selfinduced vomiting in a patient with anorexia nervosa and bulimia. Cocaine free-base vapor has been hypothesized to result in mediastinal and subcutaneous emphysema by causing areas of pulmonary parenchymal necrosis and secondary air and leakage. I2 Reports also exist of pneumomediastinum subcutaneous emphysema occurring without ti history of coughing, emesis, aspiration, or trauma.13 A perforation or erosion of any portion of the gastrointestinal tract may result in subcutaneous emphysema. Boerhaave’s syndrome is a spontaneous rupture of the esophagus resulting in pneumomediastinum, pneumothorax, and subcutaneous emphysema. It is most commonly observed in alcoholics with severe vomiting, but it may be associated with any increase in abdominal pressure, including childbirth, seizures, weight lifting. or blunt abdominal trauma.13 Other instances of subcutaneous emphysema with a gastrointestinal origin include perforated peptic ulcer, rectal trauma, enteritis, intestinal obstruction, diverticulitis, appendicitis, carcinoma of the colon, and an anal fistula.14 Factitious subcutaneous emphysema may result from selfinflicted injury to the buccal mucosa and hyperinflation of the cheeks15 and by self-induced skin punctures.16 Spontaneous subcutaneous emphysema may result from infections with gas-forming organisms including clostridia,

HOPKINS

ET AL n SPONTANEOUS

SUBCUTANEOUS

EMPHYSEMA

anaerobic streptococci, coliforms. hemolytic staphylococci, and streptococci.” Gas-producing infections not associated with trauma or surgery tend to occur in patients with immune or circulatory compromise, diabetes being the most common underlying disorder.” Fournier’s gangrene, a fulminating gas gangrene of the male genitalia, may present as a gas-forming infection of the scrotum. I9 Gas-producing infections rarely may present in an uncompromised individual.‘” COMPLICATIONS AND TREATMENT Conservative management is indicated in the majority of cases of subcutaneous emphysema because it is usually a self-limited condition and spontaneous remission usually occurs. Initial efforts must be made to detect the underlying cause of the subcutaneous emphysema in order that appropriate management may be undertaken. Occasional reports exist of complications secondary to subcutaneous emphysema. These include upper airway obstruction3 increased intracranial pressure*’ and soft-tissue calcification,2’ difficult mechanical ventilationz3 and rarely, acute respiratory failure.24,25 Decompression of the subcutaneous air may be achieved by surgical incision.14 Despite the alarming appearance of this child, conservative therapy resulted in a resolution of both the bronchiolitis and the complication of subcutaneous emphysema. REFERENCES 1. Mattox KL, Allen MK: Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema. Injury 1986;17:309-312 2. Macklin MT, Macklin CC: Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: An interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944;23:281-358 3. Steffy WR, Cohn AM: Spontaneous subcutaneous emphysema of the head, neck, and mediastinum. Arch Otolaryngol Head Neck Surg 1974;100:32-35 4. Millord CE: Pneumomediastinum. Dis Chest 1969;56:297300 5 Kirsh MM, Orvald TO: Mediastinal and subcutaneous emphysema complicating acute bronchial asthma. Chest 1970;57: 580581

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6. Ozonoff MB: Pneumomediastinum associated with asthma and pneumonia in children. Am J Roentgen01 1965;95:11217 7. Brock C, Meyer H: Subcutaneous emphysema associated with Stevens-Johnson syndrome. Clin Pediatr 1982;21:631 8. Amin NM, Anokbonggo WW, Williams PN: Subcutaneous emphysema as a complication of measles. East Afr Med J 1972; 491346-354 9. Hamman L: Mediastinal emphysema. JAMA 1945;128:1 10. Girard DD, Carlson V, Natelson EA, et al: Pneumomediastinum in diabetic ketoacidosis: Comments on mechanism, incidence, and management. Chest 1971;60:455-459 11. Overby KJ, Litt IF: Mediastinal emphysema in an adolescent with anorexia and self-induced emesis. Pediatrics 1988;81: 134-l 36 12. Khouzam N: The cocaine user who looked like a bullfrog. Hosp Pratt 1986;21 :157-l 58 13. Thawley SE: Air in the neck. Laryngoscope 1974;84:14451453 14. Oetting HK, Kramer NE, Branch WE: Subcutaneous emphysema of gastrointestinal origin. Am J Med 1955;19:872-886 15. McGraw ME, Price DA, Postlethwrite PJ: Subcutaneous emphysema: A new form of self abuse. Arch Dis Child 1984;59: 990-992 16. Rauh JL: Self-induced subcutaneous emphysema in an adolescent. J Pediatr 1979:88:690-691 17. Vo NM, Watson S, Bryant LR: Infections of the lower extremities due to gas-forming and non-gas-forming organisms. South Med J 1986;79:1493-1495 18. Mayer G, Kang R: Gas gangrene, diabetes, and cholecystitis. Am J Emerg Med 1985;3:42-45 19. Nielsen OS, Jensen SK: Fournier’s gangrene presenting as gas-forming subcutaneous infection of the scrotum. Stand J Urol Nephrol 1983;17:245-247 20. Porter RC, Smith HG, Hutto JO, et al: Clostridial myonecrosis: An unusual presentation. Pediatr Infect Dis 1984;3:340342 21. Coelho JCU, Tonnesen AS, Allen SJ, et al: Intracranial hypertension secondary to tension subcutaneous emphysema. Crit Care Med 1985;13:512-513 22. Naideck HJ, Chawla HS: Soft-tissue calcification after subcutaneous emphysema in a neonate. Am J Roentgen01 1982; 1391374-376 23. Bard PA, Chen L: Subcutaneous Emphysema Associated with Laparoscopy. Anesth Analg 1990;71 :lOl-102 (letter) 24. Conetta R, Barman AA, lakorou C, et al: Acute ventilatory failure from massive subcutaneous emphysema. Chest 1993; 104:978-980 25. Eveloff SE, Donat WE, Aisenberg R, et al: Pneumatic chest wall decompression: A cause of respiratory failure from massive subcutaneous emphysema. Chest 1991;99:1021-1023