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JAIN, SADHANA, GUPTA : SUBCUTANEOUS EMPHYSEMA FOLLOWING INTUBATION. 215

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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.