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JAIN, SADHANA, GUPTA : SUBCUTANEOUS EMPHYSEMA FOLLOWING INTUBATION. Indian J. Anaesth. 2002; 46 (3) : 215-216

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LOCALISED SUBCUTANEOUS EMPHYSEMA FOLLOWING INTUBATION-A CASE REPORT.

Dr. Subodh Jain1 Dr. Sadhana Jain2 Dr. H. K. Gupta 3 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.
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.

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 examination there 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

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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 small cuff, 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 during extubation. It was not related to insufflation of air in peritoneal cavity. The distensibility of sub-mucosal tissue of larynx particularly supraglottic portion, permit the rapid 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 torn there 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.