pneumomediastinum following dental procedure · complications: cardiac/pulmonary failure, air...
TRANSCRIPT
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G.Nakov, G.Kirova Tokuda Hospital Sofia
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A 3-year old girl with no previous serious
known diseases Swelling of the face and neck during a
prolonged dental procedure under general anesthesia
Case report
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In the ICU: Subcutaneous emphysema at the level of the head, neck
and thorax Afebrile Normal blood analysis Normal pulmonary auscultation finding, heart rate
140/min, blood pressure 100/60 mmHg 100% oxygen saturation with oxygen mask
Case report
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Case report – imaging findings
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Case report – imaging findings
Did we really need it?
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Case report – imaging findings
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Case report – imaging findings
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Bronchoscopy found no pathology, neither did
the oesophagoscopy After oxygen therapy and antibiotic prophylaxis
the patient was discharged from the hospital
Our diagnosis
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Our diagnosis
Spontaneous pneumomediastinum, pneumoperitoneum and
retropneumoperitoneum induced by a dental procedure
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For the first time described in the early 20th century by Turnbull
Turnbull A. A remarkable coincidence in dental surgery. Br Med J 1900;1:1131
Subcutaneous emphysema, after tooth extraction and a Valsalva maneuver
Since the 1960s high-end air-speed drills are used in dentistry
Barkdull TJ. Pneumothorax during dental care. J Am Board Fam Pract. 2003;Mar-Apr; 16(2):165-9
Most of them nowadays have air and water coolers
Discussion
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Discussion – potential spaces
Direct communication of the base of the 1st, 2nd and 3rd molar roots with the sublingual and submandibular spaces
www.exodontia.info/LudwigsAngina.html
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Discussion – potential spaces
The submandibular space communicates with the retropharyngeal space and the latter is continuous with the mediastinum
Frias Vilaça et al; Insights into Imaging. 2013;4:759
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Discussion – potential spaces
Communication of
the mediastinum and retroperitoneum at the level of the foramina of Morgagni (sternocostal triangles) and the oesophageal and aortic hiatus
Frias Vilaça et al; Insights into Imaging. 2013;4:759
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Clinical examination: dyspnea, chest pain,
edema, crepitus sound, erythema, odynophagia, Hamman’s sign
Patient’s history Blood test may be normal
Chest X-rays (PA/AP/laterography) and/or CT
to confirm the diagnosis
Diagnosis
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Early recognition is important Usually a self-resolving condition, but potentially life-
threatening Administration of 100% oxygen Antibiotic prophylaxis (amoxicillin + clavulanic acid) Observation and conservative treatment lead to resolution
in 2 to 3 (up to 14) days in mild to moderate cases In severe cases tracheostomy may be necessary
Management
Karras SC et al; Cervicofacial and mediastinal emphysema as the result of a dental procedure. J Emerg Med. 1996;149- 13 Josephson GD et al; Subcutaneous cervicofacial and mediastinal emphysema after dental instrumentation. Otolaryngol Head Neck Surg. 2001;124:170- 171
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Importance
The significance of
pneumomediastinum and the potential spaces is that severe and potentially life-threatening complications may occur
Frias Vilaça et al; Insights into Imaging. 2013;4:759 Wakoh M et al; Dentomaxillofac Radiol. 2000;29:201 Frühauf J et al; Arch Dermatol. 2005;Nov;141:1437
„Danger space“ Grodinsky M, Holyoke EA.,. Am J Anat 1938;63:367
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Complications: cardiac/pulmonary failure, air embolism,
pneumopericardium, pneumothorax, pneumoperitoneum, optic nerve damage, infection/sepsis, compression syndromes
Sandler CM, Libshitz HI, Marks G. Pneumoperitoneum, pneumomediastinum and pneumopericardium following dental extraction. Radiology 1975;115:539-540
Rickles NH, Joshi BA. Death from air embolism during root canal therapy. Possible cause in a human and an investigation in dogs. J Am Dent Assoc. 1963;67:390
Wide range of differential diagnosis - hematoma, cellulitis, allergic reactions, angioedema, subcutaneous emphysema, necrotizing fasciitis, acute contact dermatitis, Melkersson-Rosenthal syndrome
Frühauf J et al; Soft tissue cervicofacial empysema after dental treatment: report of 2 cases with emphasis on the differential diagnosis of angioedema. Arch Dermatol. 2005;141:1437
Mather AJ et al; Cervicofacian and mediastinal emphysema complicating a dental procedure. J Can Dent Assoc. 2006;72:565
Importance
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Emergency condition Radiographs and CT to prove the diagnosis Wide range of differential diagnosis Usually self-resolving, but life-threatening
complications Importance of the potential spaces for the
spreading and outcome of the condition
Take home message
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1. Turnbull A. A remarkable coincidence in dental surgery. Br Med J 1900;1:1131 2. Barkdull TJ. Pneumothorax during dental care. J Am Board Fam Pract. 2003;Mar-Apr; 16(2):165-9 3. www.exodontia.info/LudwigsAngina.html 4. Frias Vilaça A, Reis AM, Vidal IM. The anatomical compartments and their connections as demonstrated by ectopic air. Insights into Imaging. 2013;4(6):759-772 5. Wakoh M, Saitou C, Kitagawa H, Suga K, Ushioda T, Kuroyanagi K. Computed tomography of emphysema following tooth extraction. Dentomaxillofac Radiol. 2000; Jul;29(4):201-8 6. Frühauf J, Weinke R, Pilger U, Kerl H, Müllegger RR. Soft tissue cervicofacial empysema after dental treatment: report of 2 cases with emphasis on the differential diagnosis of angioedema. Arch Dermatol. 2005;Nov;141(11):1437-40 7. Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat 1938;63:367-408 8. Mather AJ, Stoykewych AA, Curran JB. Cervicofacian and mediastinal emphysema complicating a dental procedure. J Can Dent Assoc. 2006;Jul-Aug;72(6):565-8 9. Karras SC, Sexton JJ. Cervicofacial and mediastinal emphysema as the result of a dental procedure. J Emerg Med. 1996;149- 13 10. Josephson GD, Wambach BA, Noordzji JP. Subcutaneous cervicofacial and mediastinal emphysema after dental instrumentation. Otolaryngol Head Neck Surg. 2001;124:170- 171 11. Sandler CM, Libshitz HI, Marks G. Pneumoperitoneum, pneumomediastinum and pneumopericardium following dental extraction. Radiology 1975;115:539-540 12. Rickles NH, Joshi BA. Death from air embolism during root canal therapy. Possible cause in a human and an investigation in dogs. J Am Dent Assoc. 1963;67:390
References
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Thank You!