Abstract
Introduction
Subcutaneous emphysema [SCE] can develop due to traumatic, infectious, and spontaneous causes and usually localizes to the periorbital space.
Case
We present a case of an 18-year-old male with an 8-day history of migraine-like headaches followed by the acute onset of frontofacial swelling after vigorous sneezing. Radiologic and physical exam findings supported a diagnosis of frontofacial SCE in the setting of frontal sinusitis.
Discussion
A sneeze, although usually benign, causes a significant increase in intranasal pressure. When coupled with a history significant for facial trauma or rhinosinusitis, this rise in pressure can be sufficient to cause fracturing of the bone overlying a paranasal sinus, leading to the formation of SCE.
1
Introduction
Subcutaneous emphysema [SCE] of the head has been reported due to a variety of etiologies including traumatic , infectious , and spontaneous . Most cases of facial emphysema involve the periorbital region, and to our knowledge no report exists of the acute onset of frontal emphysema. We present a patient with underlying frontal sinusitis who developed the rapid onset of forehead emphysema after a vigorous episode of sneezing.
2
Case report
An 18-year-old male boxer with a medical history significant for rheumatic fever, migraine, and tobacco use was transferred from an outside emergency department with an 8-day history of headaches with light sensitivity and worsening facial pain. The patient denied any history of recurrent acute or chronic sinusitis, nasal trauma, or sinonasal surgery, but did report an upper respiratory infection two weeks prior to evaluation. On the day prior to admission, he developed the acute onset of painful swelling over his forehead after a violent episode of sneezing. The patient denied fevers, chills, nausea, vomiting, vision loss, diplopia, mental status changes, or dizziness. Physical examination demonstrated equal, round, and reactive pupils with intact extraocular movements and no evidence for change in visual acuity. Erythema and induration were noted overlying the frontal sinuses and extending down over the glabella, and subcutaneous emphysema was palpated along the hairline. The patient was in no acute distress and showed no focal neurologic deficits.
Computed tomography (CT) revealed air fluid levels in bilateral frontal sinuses, with a small defect in the left anterior table and emphysema overlying the left forehead ( Fig. 1 ). Magnetic resonance imaging (MRI) was ordered to rule out intracranial involvement and demonstrated significant pan-sinus opacification, most pronounced in the bilateral frontal region ( Figs. 2 and 3 ). Extensive extracranial soft tissue enhancement was demonstrated, consistent with soft tissue extension of frontal infection, although no subperiosteal abscess was identified to suggest Pott’s puffy tumor. There was no abnormal enhancement of brain parenchyma, cavernous sinuses, or leptomeninges, nor any intracranial fluid collections to suggest CNS extension of infection.
The patient was started on intravenous broad spectrum antibiotics, which led to the rapid improvement in symptoms including frontal edema and crepitus. The patient was discharged on two weeks of amoxicillin/clavulanate and was asymptomatic at the time of follow-up. A subsequent CT scan demonstrated improved but still present mucosal changes across all sinuses; nasal endoscopy at this time showed no evidence of purulent rhinorrhea, polyp, mass, or mucosal inflammation. Options including conservative management versus surgical intervention were discussed, but the patient was ultimately lost to follow-up.
2
Case report
An 18-year-old male boxer with a medical history significant for rheumatic fever, migraine, and tobacco use was transferred from an outside emergency department with an 8-day history of headaches with light sensitivity and worsening facial pain. The patient denied any history of recurrent acute or chronic sinusitis, nasal trauma, or sinonasal surgery, but did report an upper respiratory infection two weeks prior to evaluation. On the day prior to admission, he developed the acute onset of painful swelling over his forehead after a violent episode of sneezing. The patient denied fevers, chills, nausea, vomiting, vision loss, diplopia, mental status changes, or dizziness. Physical examination demonstrated equal, round, and reactive pupils with intact extraocular movements and no evidence for change in visual acuity. Erythema and induration were noted overlying the frontal sinuses and extending down over the glabella, and subcutaneous emphysema was palpated along the hairline. The patient was in no acute distress and showed no focal neurologic deficits.
Computed tomography (CT) revealed air fluid levels in bilateral frontal sinuses, with a small defect in the left anterior table and emphysema overlying the left forehead ( Fig. 1 ). Magnetic resonance imaging (MRI) was ordered to rule out intracranial involvement and demonstrated significant pan-sinus opacification, most pronounced in the bilateral frontal region ( Figs. 2 and 3 ). Extensive extracranial soft tissue enhancement was demonstrated, consistent with soft tissue extension of frontal infection, although no subperiosteal abscess was identified to suggest Pott’s puffy tumor. There was no abnormal enhancement of brain parenchyma, cavernous sinuses, or leptomeninges, nor any intracranial fluid collections to suggest CNS extension of infection.
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