Subcutaneous emphysema secondary to foreign-body aspiration

Subcutaneous Emphysema: An Outlandish Hint to an Impacted Tracheobronchial Foreign Body

Tracheobronchial foreign body aspiration amongst paediatric population is one of the commonest challenges faced by the otolaryngologist. Subcutaneous emphysema is an uncommon presentation of this condition and the ENT specialist needs to have a high index of clinical suspicion of a foreign body. We report a case of 2-year old child presented with subcutaneous emphysema later diagnosed with a foreign body in the bronchus.

Pneumomediastinum Secondary to Foreign Body Aspiration: Clinical Features and Treatment Explorement in 39 Pediatric Patients

BACKGROUND

Pneumomediastinum (PM) secondary to foreign body aspiration (FBA) is rare in children. Although it is mainly benign, some cases may be fatal. Due to the rare nature of this clinical entity, proper assessment and management have been poorly studied so far. Here, we characterized the presentation and management of this clinical entity and provided an evaluation system for the management.

METHODS

We retrospectively reviewed children with PM secondary to FBA, who were treated in Beijing Children's Hospital from January 2010 to December 2015. All patients were stratified according to the degree of dyspnea on admission, and interventions were given accordingly. Bronchoscopic removals of airway foreign bodies (FBs) were performed on all patients. For patients in acute respiratory distress, emergent air evacuation and/or resuscitations were performed first. Admission data, interventions, and clinical outcomes were recorded.

RESULTS

A total of 39 patients were included in this study. The clinical severity was divided into three grades (Grades I, II, and III) according to the degree of dyspnea. Thirty-one patients were in Grade I dyspnea, and they simply underwent bronchoscopic FBs removals. PM resolved spontaneously and all patients recovered uneventfully. Six patients were in Grade II dyspnea, and emergent drainage preceded rigid bronchoscopy. They all recovered uneventfully under close observation. Two exhausted patients were in Grade III dyspnea. They died from large PM and bilateral pneumothorax, respectively, despite of aggressive interventions in our hospital.

CONCLUSIONS

PM secondary to FBA could be life-threatening in some patients. The degree of dyspnea should be evaluated immediately, and patients in different dyspnea should be treated accordingly. For patients in Grade I dyspnea, simple bronchoscopic FBs removals could promise a good outcome. For patients in Grade II dyspnea, emergent air evacuation and/or resuscitation should precede a bronchoscopy before the children become exhausted.

Rigid bronchoscopy and balloon dilation for removal of aspirated thumbtacks: case series and literature review

OBJECTIVE

Aspirated thumbtacks can pose unique challenges during removal due to their shape. In particular, the flanges of the thumbtack can readily become trapped by the bronchial mucosa during extrication. We describe our experience of three children from whom aspirated thumbtacks were removed using rigid bronchoscopy following balloon dilation of the airway to reduce bronchial mucosa entrapment.

METHODS

This is a retrospective review of three pediatric otolaryngology cases.

RESULTS

In all three cases, the thumbtack was successfully removed from various sites within the lower respiratory tract. There were no iatrogenic complications, in particular bronchial wall injury leading to pneumothorax.

CONCLUSION

In cases of complicated airway foreign bodies, such as thumbtacks, airway dilation is a useful and safe maneuver that may help facilitate removal.

[Subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumorachis, and pneumoretroperitoneum revealing an unknown foreign body aspiration]

Subcutaneous emphysema develops from the spread of air essentially from the mediastinum into the subcutaneous tissue causing progressive distension and infiltration. Diagnostic and therapeutic delay expose the patient to massive air effusion and risk of compression of cervical and mediastinal structures. The initial mechanism is a breach in the tracheobronchial tree with air diffusion into the interstitial space and along the perivascular spaces toward the mediastinum, and then spread and dissection in the subcutaneous tissue. A tracheobronchial foreign body is a very rare cause of emphysema and is often localized. An association with a combination of epidural emphysema, pneumopericardium, or pneumoretroperitoneum is exceptional. Here, we present a unique case associating massive subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumorrhachis, and pneumoretroperitoneum in a 3.5-year-old child complicating an unrecognized aspirated foreign body. The extraction of the foreign body resulted in gradual regression of the symptoms and the disappearance of these emphysematous locations.

Comparison between tracheal foreign body and bronchial foreign body: a review of 1,007 cases

OBJECTIVE

To determine the differences between tracheal foreign body aspiration and bronchial foreign body aspiration.

METHODS

This retrospective study includes 1007 patients with the diagnosis of foreign body aspiration according to rigid bronchoscopy. Patients were divided into two groups: tracheal and bronchial foreign body groups. Age, sex, clinical presentation, pre-operative radiographic findings, rigid bronchoscopy findings, types of foreign body, and the complications of each group were observed and analyzed.

RESULTS

Out of 989 study patients, there were 146 patients (14.5%) in the tracheal foreign body group and 843 patients (83.7%) in the bronchial foreign body group. Eighteen patients with FBs located in the larynx and presenting with multiple FBs located in the tracheal and bronchial regions were excluded from this study. The majority of the patients were under the age of three for both groups. The male to female ratio was significantly higher in the bronchial foreign body group (P<0.001). More patients in the bronchial foreign body group were misdiagnosed upon first clinical visit (P=0.001), referred from another hospital (P<0.05), or had delayed diagnosis (P<0.05). The most prominent symptom in both groups was cough, followed by decreased breath sounds, wheezing, and dyspnea. More patients in the bronchial foreign body group experienced decreased breath sounds (P<0.001), while more patients in the tracheal foreign body group experienced dyspnea (P<0.05). Chest fluoroscopy abnormalities were observed at a higher frequency in the bronchial foreign body group (P<0.001). Lateral neck X-ray results showed higher frequencies of abnormalities in the tracheal foreign body patients. Out of 30 patients in the tracheal foreign body group received a CT scan, 27 had abnormal scan results, while all 253 patients in the bronchial foreign body subgroup had abnormal results. The majority of foreign bodies were organic materials and were removed by rigid bronchoscopy at the first clinical session in 96.6% of tracheal foreign body cases and 96.0% of bronchial foreign body cases (P=0.727). Major complications, including one death, were observed only in the bronchial foreign body group.

CONCLUSIONS

The nature of tracheal foreign body aspiration is different from bronchial aspiration. Clinical presentation and pre-operative radiographic findings are helpful for diagnosis. The clinician should understand the differences between tracheal and bronchial FB cases and provide the appropriate management when either is presented.

Subcutaneous emphysema: an unusual presentation of foreign body aspiration

Two cases of subcutaneous emphysema owing to foreign body aspiration are described. In case 1, a 2½-year-old boy presented with complaints of respiratory distress, cough, and swelling over neck. Computed tomography scan of neck and thorax revealed subcutaneous emphysema along with emphysematous changes of left lung. In Case 2, a 5-year-old boy presented with left pneumothorax along with massive subcutaneous emphysema, extending from the face to the chest. Computed tomography scan of the chest revealed subcutaneous emphysema, pneumomediastinum, and left pneumothorax. Both of the patients underwent bronchoscopic removal of the foreign body from the left main bronchus. At present both are asymptomatic and doing well. Subcutaneous emphysema is rare as a manifestation of foreign body aspiration and this cause should be kept in mind, even in the absence of forthcoming history of aspiration.

Subcutaneous emphysema due to bronchial foreign body demonstrated by multidetector-row computed tomography

Foreign body aspiration is an important cause of emergency hospital admissions in young children less than 3 years of age. It may manifest with acute respiratory difficulty, choking and wheeze acutely or may be asymptomatic. Surgical emphysema is an unusual presentation of bronchial foreign body aspiration in young children. We describe an infant with bronchial foreign body aspiration that manifested with subcutaneous emphysema and pneumomediastinum. Multidetector-row CT with virtual bronchoscopy helped in the diagnosis by detecting and localizing the intraluminal foreign body in the right main bronchus that was removed with rigid bronchoscopy.

Pneumothorax, pneumomediastinum, and pulmonary embolism

This article discusses pneumothorax, pneumomediastinum, and pulmonary embolism in pediatric practice. Although children appear to have better outcomes than adults, the risk factors are substantial. Topics covered include the pathophysiology incidence, presentation, diagnosis, and management of these diseases.

Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: The Macklin effect

OBJECTIVE

We describe the clinical features of a 17-year-old girl with severe asthma exacerbations. On admission to the intensive care unit, she manifested expiratory dyspnea, cyanosis, and an unproductive cough. Her chest x-rays showed extensive pneumomediastinum (PM), mild subcutaneous emphysema at the right anterior triangle of the neck, and right upper-lobe atelectasis. Her PM resulted from the "Macklin effect," which involves a three-step process: overly distended alveolar rupture, air dissection along the bronchovascular sheaths, and air spreading into the mediastinum.

METHODS

Treatment consisted of oxygen therapy, parenteral corticosteroids, and nebulized bronchodilators.

RESULTS

She made a good recovery, and was discharged from the intensive care unit after 2 days.

CONCLUSION

This case illustrates that conservative management strategies in this severe and unusual complication of asthma exacerbation can result in rapid and complete recovery. Nonetheless, every asthma exacerbation should be considered potentially life-threatening, and must be treated promptly and adequately.

A case of black magic

The authors present the case of a 64-year-old woman who presented with massive subcutaneous emphysema 2 weeks after unknowingly inhaling a Brazil nut. Foreign body inhalation should be a differential diagnosis in all such patients, with computed tomography scanning of the chest being the most appropriate investigation.