Abstract
Subcutaneous emphysema of the head and neck after otologic surgery is exceedingly rare. The mechanism relates to the intimate relationship of the temporomandibular joint to the external auditory canal. We present a rare case of subcutaneous emphysema after otologic surgery for ear disease. An astute clinical index of suspicion coupled with prompt treatment can help minimize morbidity and improve patient outcomes.
1
Introduction
The articulation of the temporomandibular joint (TMJ) in the glenoid fossa is near the external auditory canal. This consistent anatomical relationship sets the stage for potential complications arising from a dehiscence in the external auditory canal. Congenital bony tympanic plate dehiscence, trauma, tumor erosion, chronic infection, and iatrogenic causes have been described as potential sources of communication between the external auditory canal and the TMJ . Even in cases where a fistulous tract does occur, patients are generally asymptomatic and do not require treatment. More severe complications such as recurrent infection, TMJ ankylosis, persistent pain, trismus, or TMJ prolapse mandate surgical correction. Subcutaneous emphysema, however, is a rare complication that has been infrequently described in the literature. We report a case of iatrogenic surgical emphysema after ear surgery that was successfully managed with conservative measures.
2
Case report
2.1
Presentation
A 55-year-old man presented to our clinic with a history of recurrent otorrhea from a long-standing right-sided tympanic membrane perforation. Multiple courses of topical and systemic antibiotics failed to control his symptoms, and a previous underlay tympanoplasty was unsuccessful. The etiology of the perforation was unclear but thought to be related to traumatic injury from the patient’s former boxing career. Examination demonstrated a right-sided clean, anterior tympanic membrane perforation with an obstructing anterior canal wall overhang. Audiogram revealed a right-sided mild sloping to severe mixed hearing loss with 96% speech discrimination. Given the patient’s recurrent infections and previously failed repair, surgical intervention was warranted.
2.2
Intervention
The patient subsequently underwent right-sided underlay fascia tympanoplasty with mastoidotomy via a postauricular approach given the history of chronic ear drainage. Intraoperatively, a cholesteatoma pearl was excised from the epitympanum, and an approximate 50% anterior defect in the pars tensa was noted. Canalplasty with a diamond burr was necessary to obtain complete visualization and access to the annulus at the anteriormost aspect of the native tympanic membrane. Anesthetic induction, intubation, and extubation were uneventful, and the surgery was uncomplicated. A lateral canal packing and compressive mastoid dressing were applied, and postoperative oral and topical otologic antibiotics were administered per our standard protocol.
2.3
Complication
At the 1-week postoperative visit, the patient’s canal packing was removed, and the surgical site exhibited good signs of healing. Approximately 3 weeks postoperatively, the patient was seen on an urgent basis for complaints of worsening odynophagia, subjective fevers, facial and neck swelling, and an audible “squeaking” sound from his right ear. The patient denied exertional activities, nose blowing, or excessive jaw movements. Physical examination demonstrated marked facial, neck, and supraclavicular crepitus with associated mild cellulitis of the right side. Flexible fiberoptic nasopharyngolaryngoscopy was unremarkable, and no evidence of external wound dehiscence was noted. An audible air leak with jaw excursion was easily recognized, and the auditory canal was debrided, but no prolapse of the pericapsular TMJ contents was noted. A contrasted computed tomographic scan revealed a large amount of air tracking along the soft tissue planes of the right neck ( Fig. 1 ) and retropharyngeal space to the level of the cervical esophagus ( Fig. 2 ). Postoperative changes within the mastoid cavity were seen, without any evidence of apical lung pneumothorax or bony abnormalities of the tympanic plate, mesotympanum, or glenoid fossa.
2.4
Treatment and progress
The patient was admitted, and empirical intravenous broad-spectrum treatment was commenced. His right auditory canal was thoroughly debrided, and a far anterior-inferior defect in the medial bony auditory canal was recognized by the presence of air bubbles. The auditory canal was then occluded and packed with antibiotic moistened Oto-Wicks (Xomed Surgical Products, Jacksonville, FL, USA) with immediate cessation of the air leak. His therapeutic regimen was modified to include topical otologic antibacterial drops, and the patient’s clinical symptoms and examination findings rapidly improved over the following 48 hours. The patient was subsequently discharged with continued oral and topical antibiotics.
At the 1-week follow-up visit, the otologic packing was removed, and the patient demonstrated complete resolution of abnormal findings and has since remained asymptomatic.
2
Case report
2.1
Presentation
A 55-year-old man presented to our clinic with a history of recurrent otorrhea from a long-standing right-sided tympanic membrane perforation. Multiple courses of topical and systemic antibiotics failed to control his symptoms, and a previous underlay tympanoplasty was unsuccessful. The etiology of the perforation was unclear but thought to be related to traumatic injury from the patient’s former boxing career. Examination demonstrated a right-sided clean, anterior tympanic membrane perforation with an obstructing anterior canal wall overhang. Audiogram revealed a right-sided mild sloping to severe mixed hearing loss with 96% speech discrimination. Given the patient’s recurrent infections and previously failed repair, surgical intervention was warranted.
2.2
Intervention
The patient subsequently underwent right-sided underlay fascia tympanoplasty with mastoidotomy via a postauricular approach given the history of chronic ear drainage. Intraoperatively, a cholesteatoma pearl was excised from the epitympanum, and an approximate 50% anterior defect in the pars tensa was noted. Canalplasty with a diamond burr was necessary to obtain complete visualization and access to the annulus at the anteriormost aspect of the native tympanic membrane. Anesthetic induction, intubation, and extubation were uneventful, and the surgery was uncomplicated. A lateral canal packing and compressive mastoid dressing were applied, and postoperative oral and topical otologic antibiotics were administered per our standard protocol.
2.3
Complication
At the 1-week postoperative visit, the patient’s canal packing was removed, and the surgical site exhibited good signs of healing. Approximately 3 weeks postoperatively, the patient was seen on an urgent basis for complaints of worsening odynophagia, subjective fevers, facial and neck swelling, and an audible “squeaking” sound from his right ear. The patient denied exertional activities, nose blowing, or excessive jaw movements. Physical examination demonstrated marked facial, neck, and supraclavicular crepitus with associated mild cellulitis of the right side. Flexible fiberoptic nasopharyngolaryngoscopy was unremarkable, and no evidence of external wound dehiscence was noted. An audible air leak with jaw excursion was easily recognized, and the auditory canal was debrided, but no prolapse of the pericapsular TMJ contents was noted. A contrasted computed tomographic scan revealed a large amount of air tracking along the soft tissue planes of the right neck ( Fig. 1 ) and retropharyngeal space to the level of the cervical esophagus ( Fig. 2 ). Postoperative changes within the mastoid cavity were seen, without any evidence of apical lung pneumothorax or bony abnormalities of the tympanic plate, mesotympanum, or glenoid fossa.
