Senior Registrar, Maxillofacial and Oral Surgery Det~artment, Wythenshawe Hospital, Manchester

Size: px

Start display at page:

Download "Senior Registrar, Maxillofacial and Oral Surgery Det~artment, Wythenshawe Hospital, Manchester"

Marilynn Black
5 years ago
Views:

$Oral Surgery Det~artment, Wythenshawe Hospital, Manchester SURGICAL emphysema of the thorax and neck arising as a complication of injury to the pleura (with or without rib fracture), or perforation$

1 SURGICAL EMPHYSEMA OF THE FACE, NECK, AND UPPER THORACIC WALL ASSOCIATED WITH FRACTURE OF THE FACIAL SKELETON By IAN H. HESLOP, M.B., B.S., B.D.S., F.D.S., R.C.S. Senior Registrar, Maxillofacial and Oral Surgery Det~artment, Wythenshawe Hospital, Manchester SURGICAL emphysema of the thorax and neck arising as a complication of injury to the pleura (with or without rib fracture), or perforation of the trachea or oesophagus, is widely recognised and has been frequently reported. Numerous cases are recorded in the literature of this condition following rupture of congenital bulla~ of the lung, and less extensive emphysema of the neck on one or both sides has followed tonsillectomy on a number of occasions. More or less localised emphysema of the face, in a few cases involving the neck on one or both sides, has been reported following upon dental procedures. Turnbull first recorded in I9OO emphysema of the face in a ship's bugler who resumed his duties after removal of an upper tooth. Similar cases are recorded by McFadyean (I943), Shafto (I945), Edwards (i948), Whittaker (I948), Brown (I949), and Penney (I949), some of these patients giving a history of violent nose blowing or blowing with the mouth soon after extraction. Fuller (I93 o) and others have described emphysematous swelling of the face following the use of a compressed air syringe in root canal therapy of upper teeth. The occurrence of fracture of the facial skeleton in the region of the ethmoid air cells is believed by Murray (I949) to be accompanied by some degree of surgical emphysema in a high proportion of cases, and he suggests that the interstitial air in the tissues of the orbit and eyelids in such cases is often overlooked. In his article he describes six cases of orbital emphysema which resulted from escape of air through fractures in the paper-thin walls of the ethmoid air cells, which form part of the medial wall of the bony orbit. These fractures had been caused by local physical violence applied to the region of the eyes and nose ; in all cases the fractures were minute and the emphysema did not extend much beyond the confines of the orbit. Linhart (I943) describes seven cases of emphysema of the orbit, stressing that the condition was almost always due to a fracture of the nasal-orbital wall accompanied by nose blowing. The condition has been reported by Martin (I928) following violent nose blowing alone without any history of trauma to the face or evidence of fracture. When the presence of surgical emphysema of the face in more gross fractures of the facial skeleton is considered, three points of interest present themselves. First, in view of the multiple communications which must exist between the mouth, nose, and paranasal sinuses and the tissue planes, is it not surprising that extensive surgical emphysema of the face and neck is not a more common accompaniment of such fractures? This thought applies particularly in connection with the moderately severe or severe fracture of the middle third of the facial skeleton, where breaks in the walls of the air sinuses are very numerous. Secondly, is the 3 E* 243

244 BRITISH JOURNAL OF PLASTIC SURGERY explanation for the apparent rarity of the condition that such patients seldom attempt to clear the nasal air passages of blood and mucus by blowing the nose,

2 244 BRITISH JOURNAL OF PLASTIC SURGERY explanation for the apparent rarity of the condition that such patients seldom attempt to clear the nasal air passages of blood and mucus by blowing the nose, and are content to breathe through the mouth? The third point of interest arises out of the observations of Murray (1949) on orbital emphysema. Is surgical emphysema of the face in fact quite common, at least in middle third fractures, and does it frequently go undetected because it is not looked for? Where high pyramidal fractures involving the cribriform plate of the ethmoid and breaching of the dura mater are under consideration, this same query should be raised concerning the incidence of traumatic cerebral aerocoele. Is this condition also frequently missed? Jeannin (I87O) and Hubrich (1942) have recorded surgical emphysema in the presence of fracture of the maxillary sinus, and of the very few recorded cases of surgical emphysema reported in association with major fractures of the facial skeleton, Villar (1927) and Bonnet (I93 I) each describe one in which there was a maxillary fracture. CASE REPORT The patient, a man of 30 years of age, was found lying semi-conscious in the roadway beside a motor-cycle which he had been riding. He remembered nothing of the accident or of the events leading up to it, and he was uncertain of his movements during the preceding four or five hours. He was taken to a hospital near the scene of the accident and on admission was described as being noisy and restless, but was much more co-operative by the next day, when he was considered fit for transfer to this hospital. Condition on Admission.--His general condition was fairly good, and he responded sensibly to questioning, though he was still a little drowsy. His blood-pressure was 14o/9o ram. Hg, the pulse was of good volume and remained steady at around 72 per rain., and the routine general and neurological examination showed no abnormality. Apart from the maxillofacial injuries, the only damage elsewhere in the body was slight bruising of the right leg and the left knee. Clinical examination of the injured area showed the presence of the following features :-- Extra-orally.--A. On Inspection.--Gross swelling of the whole of the face, particularly the eyelids, so that the eyes were almost closed and it was not possible to establish whether or not any diplopia was present. Marked swelling in the region of the left angle and left body of the mandible. Less marked swelling of the neck and upper anterior thoracic wall (Fig. I). Right and left circumorbital ecchymosis. Left subconjunctival hmmorrhage. Hmmorrhage from the right external auditory meatus, and ha:morrhage and leakage of cerebrospinal fluid from the nose. Lacerations of the left eyebrow, upper lip, and chin. These had been sutured before admission to this hospital. B. On Palpation.--Marked surgical emphysema was present from the supraorbital ridges above to the line of attachment of the platysma over the upper thoracic wall below, and laterally to the posterior border of the mandible, and in the neck posteriorly as far as the sternomastoid region on each side. The patient had blown his nose repeatedly in an effort to clear the obstruction due to blood clot in the nasal passages. There was tenderness over both zygomatic bones, over the left angle and left body of the mandible.

3 SURGICAL EMPHYSEMA OF THE FACE~ NECK~ AND UPPER THORACIC WALL 245 FIG. I Full face and right and left profile views of the patient on admission showing the gross swelling of the face and neck, much of which was due to surgical emphysema.

$No definite step deformities were palpable at the sites of suspected fractures, but some separation could be felt in the region of the left fronto-malar suture. FIG.$ $2 Occipitomental radiograph with arrows pointing to the main fracture sites. Dark shadows in upper parts of each orbit are due to the orbital emphysema. C. Neurological Examination.$

4 246 BRITISH JOURNAL OF PLASTIC SURGERY The nose was tender and many mobile bone fragments were palpable. No definite step deformities were palpable at the sites of suspected fractures, but some separation could be felt in the region of the left fronto-malar suture. FIG. 2 Occipitomental radiograph with arrows pointing to the main fracture sites. Dark shadows in upper parts of each orbit are due to the orbital emphysema. C. Neurological Examination.--There was ana:sthesia in the areas of distribution of the left infraorbital and left inferior dental nerves Intra-orally.--A. On Inspection were present. There was an obvious fracture of the left body of the mandible between/5 and/7, compound into the oral cavity, with a hmmatoma in the adjacent buccal sulcus and in the floor of the mouth. The bite was gagged on the posterior teeth on the right side. B. On Palpation.--The mandibular fracture was confirmed. The maxilla was freely mobile and had been displaced downwards and backwards. Radiographic Examination.--This showed numerous fracture sites through which air might have passed from the mouth, the nose, or the paranasal sinuses into the tissue planes of the neck and face (Fig. 2). Radiologically there was fracture of: (I) The left body of the mandible; (2) the right zygomatic arch; (3) the left zygomatic complex, with rupture of the walls of the antrum ; (4) the nasal bones ; (5) the maxilla--(a) a low-level Guerin type of fracture

5 SURGICAL EMPHYSEMA OF THE FACE~ NECK~ AND UPPER THORACIC WALL 247 FIG. 3 Full face and right and left profile views on twenty-eighth post-operative day.

$248 BRITISH JOURNAL OF PLASTIC SURGERY running through the lower portions of both antra and the nasal cavity; (b) a high-level pyramidal type of fracture running up across both antra and through the$

6 248 BRITISH JOURNAL OF PLASTIC SURGERY running through the lower portions of both antra and the nasal cavity; (b) a high-level pyramidal type of fracture running up across both antra and through the lateral wall of the nasal cavity on each side, and up to the cribriform plate of the ethmoid bone. Diseussion.--Almost all the fracture sites provided pathways for the passage of air under pressure into the tissues, but as the patient had blown his nose and had not blown with the mouth, the mandibular fracture site could be ruled out as a pathway in this particular case. The probable sites of escape of air are the breaches in the walls of the nose and antra, and as the patient had a frank cerebrospinal rhinorrhoea it is surprising that he did not develop a traumatic cerebral aerocoele as well as the surgical emphysema of the face and neck. There was no clinical or radiographic evidence to suggest that an aeroc~ele was oresent. During the operation for reduction and immobilisation of the fractures it was interesting to observe that when an incision was made in the left cheek for placing of a bone pin in the main zygomatic fragment, there was a considerable escape of sanguineous bubbles from the wound. There is some evidence of the orbital portion of the emphysema in the upper parts of each orbit on the occipitomental radiograph (Fig. 2). This shows as a dark shadow overlying the frontal sinus on each side and extending laterally beyond the sinus shadow. This appearance is similar to that demonstrated by Murray (1949) in his cases of orbital emphysema. Fig. 3 shows the patient on the twenty-eighth post-operative day when the facial contour had returned to normal. Some scar revision will be needed in the region of the left eyebrow. SUMMARY The occurrence of surgical emphysema of the face and neck is briefly described with special reference to fractures of the facial skeleton, and the literature on the subject is reviewed. A case is reported of surgical emphysema of the face, neck, and upper thoracic wall associated with fracture of the maxilla, zygomatic bones, nasal bones, and mandible in a patient who repeatedly blew his nose following his injury. I am grateful to Mr A. W. Moule, F.D.S., R.C.S., for permission to publish this case, and I should like to thank the Department of Medical Photography, Wythenshawe Hospital, for the photographs. REFERENCES BONNET, P. (1931). Lyon Chir., 28, 718. BROWN, C. J. (I949). J. oral Surg., 7, 247. EDWARDS, R. W. (1948). ft. oral Surg., 6, 147. FULLER, C. B. S. (193o). Brit. med. J., i, 862. Hr_q3RICH (1942). R6ntgenpraxis, i4, 336. JEANNIN (1870). Mdm. Soc. Sci. mdd. Lyon, 9, 304 LINHART, W. O. (1943)-.7. Amer. med. Ass., I23, 89. MCFADYEAN, K. (1943). Lancet, 2, 635. MARTIN, G. E. (1928). J. Laryng., 43, 340. MURRAY, R. S. (1949). J. Fae. Radiol., Lond., I, 121. PENNEY, H. D. (1949). Brit. dent. J., 86, 229. SHAFTO, C. E. (1945). Brit. dent. J., 78, 364. TURN'BULL, A. (19oo). Brit. med. J., x, VILLAR, R. (1927). J. Mdd. Bordeaux, 57, 4Ol. WHITTAKER, E. P. (1948). Brit. dent. J., 85, 159.

TRAUMA TO THE FACE AND MOUTH

Dr.Yahya A. Ali 3/10/2012 F.I.C.M.S TRAUMA TO THE FACE AND MOUTH Bailey & Love s 25 th edition Injuries to the orofacial region are common, but the majority are relatively minor in nature. A few are major