|Year : 2015 | Volume
| Issue : 2 | Page : 97-99
Non-traumatic, spontaneous subcutaneous emphysema: Diagnostic and therapeutic dilemma
K Venugopal, Mallikarjun M Reddy, YM Bharathraj, Jaligidad Kadappa
Department of General Medicine, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India
|Date of Web Publication||10-Apr-2015|
Department of General Medicine, Vijayanagara Institute of Medical Sciences, Room No. 17, 17th Block, Bellary - 583 104, Karnataka
Source of Support: None, Conflict of Interest: None
Subcutaneous emphysema is not an uncommon condition and occurs following a chest injury or surgical procedures. Spontaneous subcutaneous emphysema (SSE) is a rare entity, it usually present when broncho-alveolar walls are weakened by chronic lung pathology and precipitated by chronic cough. Most widely accepted mechanism is rupture of broncho-alveolar walls with escape of air into the subcutaneous plane. Usually, it will be associated with pneumothorax or pneumomediastinum. However, its occurrence without pneumothorax or pneumomediastinum has been reported in the literature. We report a case of 46 years male presented with a history of cough of 1-month duration with swelling over the face, neck and upper part of the chest. The diagnosis of SSE without pneumothorax secondary to pulmonary tuberculosis was made by examination, confirmed by chest X-ray and computed tomography imaging. The probable mechanism in our patient could be due to the existence of pleural adhesions surrounded the point of rupture.
Keywords: Nontraumatic emphysema, pig-tail catheter, pleural adhesions, pulmonary tuberculosis, spontaneous subcutaneous emphysema
|How to cite this article:|
Venugopal K, Reddy MM, Bharathraj Y M, Kadappa J. Non-traumatic, spontaneous subcutaneous emphysema: Diagnostic and therapeutic dilemma. Int J Health Allied Sci 2015;4:97-9
|How to cite this URL:|
Venugopal K, Reddy MM, Bharathraj Y M, Kadappa J. Non-traumatic, spontaneous subcutaneous emphysema: Diagnostic and therapeutic dilemma. Int J Health Allied Sci [serial online] 2015 [cited 2021 Jun 18];4:97-9. Available from: https://www.ijhas.in/text.asp?2015/4/2/97/154910
| Introduction|| |
Subcutaneous emphysema is a common condition, occurs in blunt or penetrating injury to the chest, larynx, and trachea. It also occurs as a complication of endotracheal tube insertion or intercostal tube insertion. However, presence of subcutaneous emphysema without trauma is very rare. Spontaneous subcutaneous emphysema (SSE) usually occurs secondary to rupture of subpleurally placed cavity or bullae. In these cases, it will be associated with pneumothorax. Its occurrence without pneumothorax is very rarely reported in the literature with one or two case reports to the best of our knowledge. Hence, we are reporting a case of SSE secondary to pulmonary tuberculosis without pneumothorax with special emphasis on mechanism, diagnosis, and management.
| Case report|| |
A 46-year-old nonsmoker, nonalcoholic male presented to medicine department with a history of swelling over the upper part of the body and face of 5 days duration. It was insidious in onset and gradually progressive. Initially, he noticed swelling over the upper part of the chest; it progressed over 5 days to involve neck and face. He had a history of cough since 1-month with mild expectoration. Expectoration of around 20-30 ml, blood tinged nonfoul smelling and nonmucoid whitish sputum. There was no history of asthma or pulmonary tuberculosis. There was no history of trauma. On examination, he was moderately built and nourished, conscious and oriented. General physical examination revealed pallor, cleft lip, crowding of teeth with diffuse swelling over the face, neck and upper part of the chest [Figure 1] and right axillary lymphadenopathy. He was afebrile with pulse rate of 132 beats/min, blood pressure of 90/50 mmHg, respiratory rate of 22/min and saturation of 89% at room air. On palpation, crepitus was felt over neck and anterior part of the chest. Breath sounds were diminished. There was no evidence of mediastinal shift and no other significant systemic findings. His laboratory parameters were Hb - 9.9 g%, total count - 12100 cells/cumm, polymorphs - 67%, lymphocytes - 27%, platelet count - 2.76 lakhs/cumm and erythrocyte sedimentation rate of 30 mm/1 h.
Biochemistry parameters were random blood sugar - 97 mg/dl, urea - 140 mg/dl, creatinine - 1.8 mg/dl. Sputum for acid fast Bacilli was positive for pulmonary tuberculosis. Chest X-ray revealed presence of air in the subcutaneous tissue, there was no evidence of pneumothorax, rib fractures or cavity [Figure 2]. Computed tomography (CT) thorax showed the presence of tubercular consolidation with pleural adhesions and presence of air in the subcutaneous plane [Figure 3]. Patient was observed for spontaneous resolution of emphysema since he had no signs of respiratory distress and patient treated for pulmonary tuberculosis. Patient showed improvement after 1-month follow-up.
|Figure 1: Subcutaneous emphysema involving face, neck and upper part of the chest|
Click here to view
|Figure 2: Chest X-ray posterior anterior view showing air shadows in the subcutaneous plane with no evidence of rib fracture or pneumothorax|
Click here to view
|Figure 3: Computed tomography scan of the chest showing air in the subcutaneous plane and bilateral pulmonary tuberculosis consolidation|
Click here to view
| Discussion|| |
Subcutaneous emphysema is defined as presence of air into subcutaneous tissue. The air usually appears first in the supra-clavicular spaces and then extends to other parts of the body. Neck and chest wall are the usual anatomical locations of the subcutaneous emphysema, though rarely scalp, palm of the hands, soles of the feet may be involved.  It can be traumatic or nontraumatic. Traumatic causes include blunt or penetrating trauma injury to laryngeal, tracheal, or bronchial tree. It may occur following chest tube insertion or tracheal intubation. Nontraumatic causes include coexisting structural abnormality in the lungs like infections most commonly tuberculosis, staphylococcal pneumonia, measles, pneumocystis carnii, influenza, and pertussis.  Nontraumatic emphysema can occur during the second stage of labor due to rising of the intrapulmonary pressure by excessive straining.  It may also occur from ulceration which occurs from laryngeal diphtheria,  also may be due to erosion from a foreign body.  It has also been reported as a complication of asthma with inhaled bronchodilators and nebulization as an additional risk. , It may happen due to blunt trauma, breathing in cocaine, forceful vomiting, diving injuries. 
Various theories have been postulated to explain the mechanism of SSE; Berkeley and Coffen  suggest that the origin is from a ruptured air sac and the course along the blood-vessels to the mediastinum. Alexander and Follett  maintain that violent exertion or coughing causes a rupture of pulmonary vesicles allowing the escape of air into the interlobular or interlobar spaces from which it extends to the mediastinum and thence to the rest of the body. Meyer and Lucke  present two theories. First is an ingenious one that chemical changes take place in the blood allowing diffusion of air through the walls of the alveoli into the interstitial tissues. Their second theory holds that the airs escapes through an ulcerated or eroded surface in the bronchi and passes via peribronchial or perivascular channels to the mediastinum. Bloomberg,  preexisting weakness of either the alveolar or bronchial wall exists. The increased intrapulmonary pressure because of excessive and prolonged coughing causes rupture at a weakened point allowing escape of air in the tissue. Air escapes via peribronchial or perivascular channels to the mediastinum. In the mediastinum, air spreads into loose alveolar tissue, which can then enter into the neck and subcutaneous plane in all directions. Meyer and Lucke  states that, subcutaneous emphysema may occur through the intra-pleural route provided that adhesions exist between the two layers of pleura at the point of rupture as seen in our patient. SSE can be easily diagnosed by the crunchy sensation and crepitation on palpation. Radiological studies are essential to diagnose the primary cause and extent of air leak. Routine lateral view along with posteroanterior (PA) view should be taken, it helps in diagnosing pneumomediastinum and also more sensitive than PA view. CT is helpful in diagnosing underlying lung pathology.
Treatment of SSE is usually observation as the air is absorbed in the course of few weeks. Needle puncture, which was followed earlier is not recommended as high risk of introducing infections. However, patients with hemodynamic instability and respiratory distress may need tracheostomy and skin incision (blow holes) over the neck and anterior chest wall. Subcutaneous insertion of pig-tail drains, intravenous cannulas or large bore drains may require for few patients for few days. 
| Conclusion|| |
Even though the mainstay of treatment for SSE is palliative, main aim is to evaluate for underlying lung pathology. This case reports the occurrence of SSE secondary to lung pathology and emphasis that one should not take the advantage of benign, self-limiting course of SSE since most of the times it will be associated with serious lung diseases like malignancy. The occurrence of associated intra-thoracic air leak such as pneumothorax, pneumomediastinum or pneumopericardium may complicate the scenario and requires emergent therapeutic measures. However, even the massive subcutaneous emphysema with respiratory distress in the absence of pneumothorax or pneumomediastinum may require intervention in the form of skin incision or pig-tail drains.
| References|| |
Narchi S. Fever, facial swelling and dyspnoea. Int Pediatr 2003;18:92-4.
Das M, Chandra U, Natchu M, Lodha R, Kabra SK. Pneumomediastinum and subcutaneous emphysema in acute miliary tuberculosis. Indian J Pediatr 2004;71:553-4.
Bloomberg MW. Generalized non-traumatic subcutaneous emphysema: With report of a case in a young child. Can Med Assoc J 1927;17:336-8.
Berkeley H.K AND Coffen T.H, J Am M Ass, Feb 22, 1919, lxxii, 535.
Meyer J AND Lucke B, Am J Med Sc, March, 1920, clix, 417.
Bolt RJ, Nagelkerke AF, Kneybar MC, Kopp EF, Plotz FB. Spontaneous pneumomediastinum caused by nebulization of bronchodilators in a young child. Respir Med Extra 2005;1:124-6.
Alexander ME, Follett EC. Subcutaneous emphysema: With the report of several cases, particularly one with very extensive generalized emphysema. JAMA 1919;72:930-3.
Wolfson AB, editor. Harwood-Nuss′ Clinical Practice of Emergency Medicine. 5 th
ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2010.
Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002;121:647-9.
[Figure 1], [Figure 2], [Figure 3]