Subcutaneous Emphysema and Pneumomediastinum due to Dental Extraction

The cause of SP is most often associated with bronchial asthma, other respiratory diseases such as chronic bronchitis, chronic obstructive pulmonary disease, pneumonia, bullous disease, and pulmonary alveolar microlithiasis. In the literature reviews with the large number of observations, increasing mediastinal emphysema was an indication for puncture of cellular spaces or mediastinal drainage in 6-10% of cases [1,9]. The life-threatening condition develops due to the occurrence of a valvular mechanism of air intake into the mediastinal tissue, and the progression of severe mediastinal emphysema. In this case, emergency surgery is necessary. After the intake stops, the air in the cellular spaces resolves independently. The clinical symptoms of SP are chest and neck pain, shortness of breath. Often, the air in the cellular spaces of the neck and mediastinum is asymptomatic [10, 11]. In dental practice, the development of emphysema is facilitated by the direct communication of the roots of the first, second and third molars with the sublingual and submandibular spaces, then with the pterygomandibular, parapharyngeal and retropharyngeal spaces and further with the mediastinum [6,12]. In the literature, most of the iatrogenic mediastinal emphysema is described during the preparation and filling of root canals or tooth extraction in the lower jaw and molars. Cases of the mediastinal emphysema have also been described during the dental procedures on the upper jaw using pneumatic turbine drills or pneumatic syringes [13, 14]. Pneumomediastinum is recognized on a chest X-ray in 20-90% of cases, the sensitivity of computed tomography in this pathology is 100% [3, 4, 15,16]. In our study, the introduction of air using the high-speed dental drill through the soft tissues near the root of the molar caused subcutaneous and intermuscular emphysema in the neck and spread into the mediastinum. The diagnosis was confirmed by the chest X-ray and CT scan. Emphysema developed right during the preparation of the tooth, and the procedure was immediately discontinued. The patient was referred for outpatient treatment. She was hospitalized with the increased emphysema only on the second day. The examination (fibronchoscopy, fibroesophagoscopy) was performed at the hospital to rule out other causes of the emphysema. Treatment of SP in most cases ends with spontaneous resorption of air [3,17,18]. However, such cases require hospitalization for observation in order to exclude the increasing emphysema and prevent infectious complications. Busuladzic A. et al. performed a cervical mediastinotomy to exclude necrotizing fasciitis in the patient who developed severe subcutaneous and mediastinal emphysema a few hours after the tooth filling. No signs of infection were found [6]. Patients require dynamic monitoring and preventive antibiotic therapy [19]. In our case, complete resorption of the air in the mediastinum was noted within nine days.

The use of pneumatic syringes and high-speed pneumatic turbines during tooth extraction may cause severe subcutaneous emphysema and mediastinal emphysema. Patients require exclusion of other causes of emphysema, dynamic monitoring, and preventive antibiotic therapy.

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Ethics approval and consent to participate.

This study was approved by the Institutional Review Board of Perm State Medical University, Perm, Russia, and informed consent was obtained from patient.