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From the Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Address correspondence to: Dr. David T. Wong, Department of Anesthesiology, Toronto Western Hospital, 399 Bathurst Street, McL 2-405, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: david.wong{at}uhn.on.ca
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Abstract |
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Clinical features: A 39-yr-old man had percutaneous tracheostomy done after prolonged intubation in the intensive care unit. Subcutaneous emphysema developed over the right neck fever mimicking deep sc infection resulted in neck exploration. No obvious lesion was found in the tracheobronchial tree.
Conclusion: Subcutaneous emphysema occurring after percutaneous tracheostomy could occur without significant injury to the tracheobronchial tree. We postulate that air leaking from the tracheostomy site might have been prevented by the snug fit between the tracheostomy tube and the skin, resulting in accumulation in the neck. Asymmetric dilatation of the trachea may explain the unilateral localization of the sc emphysema.
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Introduction |
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Case description |
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Three days after insertion of tracheostomy, following an episode of protracted coughing and straining, swelling and crepitations were observed on the right side of the neck. This was accompanied by erythema, fever up to 39.1°C, and moderate leukocytosis (total white count ranged between 12.1 x 109·L–1 to 18.5 x 109·L–1 with left shift). A computed tomography scan showed a significant amount of sc emphysema in the high right lateral compartment of the neck, extending to the larynx. The gas was noted to be remote from the tracheostomy site. The trachea was midline and there was no radiological evidence of tracheal tear or tracheoesophageal fistula (Figure
). A presumptive diagnosis of sc infection of the right neck was made. The patient was started on systemic antibiotics and exploration of the neck under general anesthesia was performed. Panendoscopy revealed no significant injuries to the larynx, esophagus, anterior or posterior tracheal wall. No collection of pus or hematoma was observed. The tracheostomy skin incision site was enlarged. The wound cultures taken were negative. After neck exploration and a course of antibiotics, the patient’s fever and skin erythema resolved with no serious sequelae.
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Discussion |
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Subcutaneous emphysema is a relatively uncommon complication following PDT with an incidence of 1.4%.10 Various mechanisms have been postulated as causes for development of sc emphysema. These include malpositioning, misplacement or dislocation of tracheostomy tube11 and high ventilatory pressures. Air-leak from extra luminal localization of fenestrations could lead to sc emphysema.12 Thus, the use of fenestrated tubes immediately after PDT should be avoided.10 Tears in the posterior tracheal wall, caused by the tip of the loading catheter or the tip of the dilating forceps in the guide wire dilating forceps method, have also been reported to be a cause of sc emphysema.10,13,14 Fikkers et al. demonstrated in cadavers that sc emphysema could also be caused by air leakage from the anterior tracheal wall. Air may track along the sc plane when there is a tracheal defect without a route from which the air may escape via the skin.10 Other risk factors include excessive dilatation of the anterior tracheal wall, and multiple punctures.
In the patient described, there were several features that made diagnosis of sc emphysema difficult. The delayed onset of sc emphysema after PDT was unusual. In the literature, most cases occurred within several hours after the procedure.10,13 In our patient, sc emphysema did not manifest until three days after the procedure. We hypothesized that there was no significant injury to the tracheal wall or malposition of the tracheostomy tube, as these would have resulted in immediate or rapid manifestation of sc emphysema. This was confirmed during subsequent surgical exploration of the neck. Furthermore, in a spontaneously breathing patient, the clinical manifestations of sc emphysema may also be delayed. The postulated mechanism of sc emphysema in our patient was similar to that described by Fikkers et al.10 Due to conic dilatation of the skin and trachea used in the Blue Rhino method, the fit between the tracheostomy tube and skin tends to be tight, whereas the fit between the tracheostomy tube and the trachea tends to be less snug due the cartilaginous content of the trachea. When there is high airway pressure, for example during vigorous coughing combined with blockage of the tracheostomy tube by respiratory secretions, air may track out of the anterior trachea along the cervical planes into the neck. In contrast, during surgical tracheostomy, the skin incision will allow air to leak out around the junction of skin and the tracheostomy tube to the atmosphere.
Another unusual feature observed in this patient was the presence of sc air, predominantly over the right side of the neck and remote from the site of the tracheostomy. In most cases, sc emphysema tends to be central and symmetric. However, in this patient, air was trapped primarily in the right side of the neck. We speculate that there could have been an asymmetric dilatation of the trachea during the procedure. Even with bronchoscopic guidance, more of the right side of the trachea could have been dilated during PDT, rather than the central aspect, allowing gas to track on the right side preferentially. With tracking of air and possible spillage of respiratory secretions up the neck, secondary infection on the side of the neck was expected. Previous central venous catheter insertion into the right internal jugular vein may also have contributed to superficial skin infection. However, the central venous catheter had been removed two weeks prior to the development of sc emphysema, making its contribution to the development of sc emphysema unlikely.
Within the differential diagnosis, an important cause to exclude is deep sc infection from a gas-forming organism.15 While uncommon, the presence of gas forming organisms at the site of central line placement with sc emphysema has been reported.16 The management is also vastly different, requiring extensive surgical debridement in patients with infection compared to a conservative approach in patients with sc emphysema. Patients who develop deep cervical infection usually have additional risk factors including impaired immunity, diabetes, chronic renal failure, chemotherapy, and poor nutritional states,17 and may present with systemic sepsis. Computed tomography scan features that may be helpful in differentiating necrotizing fasciitis of the neck from superficial infection include diffuse thickening of the fasciae, asymmetric thickening of cervical muscles and fluid collection in multiple neck spaces. These features were absent in our patient. Presence of a small quantity of gas on the contralateral side of the neck where the overlying skin was normal was another feature that suggested air leak as the cause of the sc emphysema.
In summary, we report a case of neck sc emphysema presenting late after an uncomplicated PDT. The cause of sc emphysema was unrelated to anterior or posterior tracheal tears, or sc infection of the neck. We postulate that the development of sc emphysema was due to the accumulation of air leaking from the anterior tracheal wall, which could not escape due to the snug fit between the tracheostomy tube and skin. Clinicians should be aware of the differential diagnosis of neck sc emphysema and be prepared to manage accordingly.
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Footnotes |
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Accepted for publication May 6, 2005. Revision accepted July 9, 2005.
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