Abstract
Subcutaneous emphysema and pneumomediastinum are rare complications following elective tonsillectomy. Although the mechanism of injury is unclear, air is thought to enter through either the buccopharyngeal mucosa during surgery or via alveolar rupture during positive pressure ventilation. Patients typically present immediately after surgery or upon anesthesia emergence. We describe a case of delayed pneumomediastinum in a 30 year-old female who presented 4 days after surgery. With only one other case described, we review the literature and remind the reader to be cognizant of this late complication.
1
Introduction
Physicians and their patients have long considered tonsillectomy a quick and simple surgery, but the procedure has always had its risks. The risks typically discussed with patients include bleeding, infection, and dehydration, while less commonly discussed complications include glossopharyngeal nerve and carotid artery injuries . An extremely rare complication, first described in 1950, is subcutaneous emphysema with subsequent pneumomediastinum . The mechanism by which air enters the subcutaneous tissue of the neck and mediastinum after surgery is unknown, but it is thought to occur through the thin buccopharyngeal mucosa of the tonsillar fossae. Alveolar rupture as a result of positive pressure ventilation during anesthetic emergence is also hypothesized to have occurred in a small number of described cases. We describe one of only two cases of post-tonsillectomy pneumomediastinum with a delayed presentation of several days, and review the literature on the topic.
2
Case presentation
A healthy 30 year-old woman had an elective tonsillectomy for chronic tonsillitis with frequent tonsillith production. Nothing unusual was noted during the surgery, which was performed under general anesthesia using a preformed oral endotracheal tube. The tonsils were removed using monopolar electrocautery, with hemostasis easily achieved using the same device. Both tonsils were adherent to the tonsillar fossae, as is typical with adult tonsillectomy for chronic disease. The patient had a bout of coughing immediately after extubation, but it quickly resolved in the post-anesthesia care unit. She was observed for four hours in the recovery area (per routine), and then was discharged home with good pain control, able to drink and tolerate a soft diet.
Four days after surgery, the patient presented to the emergency department with progressive neck pain and a persistent dry cough. She noted fullness of the right side of her neck with a “popping” sensation on palpation. She appeared uncomfortable, but was not in any acute respiratory distress. Physical examination showed the expected fibrinous exudate covering both tonsillar fossae, without any evidence of a mucosal tear or dehiscence. There was no bleeding or any clot. A chest x-ray was performed showing subcutaneous air within the right neck tracking into the mediastinum ( Fig. 1 ). There was no mediastinal shift, pneumothorax, or any evidence of focal airspace consolidation. Computerized tomography (CT) showed emphysema within the deep soft tissues of the neck from the hypopharynx to the mediastinum ( Fig. 2 ). Based on these findings, the patient was admitted for observation and treated for a cough that appeared to be exacerbating the air collection. She was also placed on intravenous clindamycin in order to prevent a mediastinal infection. Cardiothoracic surgery was consulted with the recommendation of close observation with daily imaging to follow her progress. A repeat CT of the neck on her third day of hospitalization showed decreased subcutaneous air. Despite this, she had persistent, marked difficulty swallowing and had poor oral intake. Speech pathology was consulted and performed a modified barium swallow study. This study was normal without evidence of dysphagia or aspiration, and thus, she was continued on her liquid/pureed diet. Once tolerating oral intake, she was discharged home. She was asymptomatic and in good health on follow-up one week later.
2
Case presentation
A healthy 30 year-old woman had an elective tonsillectomy for chronic tonsillitis with frequent tonsillith production. Nothing unusual was noted during the surgery, which was performed under general anesthesia using a preformed oral endotracheal tube. The tonsils were removed using monopolar electrocautery, with hemostasis easily achieved using the same device. Both tonsils were adherent to the tonsillar fossae, as is typical with adult tonsillectomy for chronic disease. The patient had a bout of coughing immediately after extubation, but it quickly resolved in the post-anesthesia care unit. She was observed for four hours in the recovery area (per routine), and then was discharged home with good pain control, able to drink and tolerate a soft diet.
Four days after surgery, the patient presented to the emergency department with progressive neck pain and a persistent dry cough. She noted fullness of the right side of her neck with a “popping” sensation on palpation. She appeared uncomfortable, but was not in any acute respiratory distress. Physical examination showed the expected fibrinous exudate covering both tonsillar fossae, without any evidence of a mucosal tear or dehiscence. There was no bleeding or any clot. A chest x-ray was performed showing subcutaneous air within the right neck tracking into the mediastinum ( Fig. 1 ). There was no mediastinal shift, pneumothorax, or any evidence of focal airspace consolidation. Computerized tomography (CT) showed emphysema within the deep soft tissues of the neck from the hypopharynx to the mediastinum ( Fig. 2 ). Based on these findings, the patient was admitted for observation and treated for a cough that appeared to be exacerbating the air collection. She was also placed on intravenous clindamycin in order to prevent a mediastinal infection. Cardiothoracic surgery was consulted with the recommendation of close observation with daily imaging to follow her progress. A repeat CT of the neck on her third day of hospitalization showed decreased subcutaneous air. Despite this, she had persistent, marked difficulty swallowing and had poor oral intake. Speech pathology was consulted and performed a modified barium swallow study. This study was normal without evidence of dysphagia or aspiration, and thus, she was continued on her liquid/pureed diet. Once tolerating oral intake, she was discharged home. She was asymptomatic and in good health on follow-up one week later.
