Abstract
Many patients and their families regard tonsillectomy as a minor operation because it is performed so commonly. However, although tonsillectomy is indeed a relatively safe surgical procedure, in extremely rare cases, it can be complicated by subcutaneous emphysema and pneumomediastinum. Although these complications resolve spontaneously in most cases, a few conclude in tension pneumothorax and other fatal complications. The mechanism by which subcutaneous emphysema and pneumomediastinum develop after tonsillectomy is poorly understood. We experienced a case in which subcutaneous emphysema, pneumomediastinum, and a deep defect in the tonsillar fossa were observed. The passage of air was shown by radiology and histopathology. Consequently, the case is reported here.
1
Introduction
Tonsillectomy is a frequently performed surgical procedure in the field of otolaryngology and is used to treat chronic tonsillitis, tonsillar hypertrophy, peritonsillar abscess and various other conditions. Although tonsillectomy is a relatively safe surgical procedure, it is nevertheless associated with several complications, including bleeding, infection, lingual edema, injury of the glossopharyngeal nerve, and injury of the carotid artery . In addition, the complications of subcutaneous emphysema and pneumomediastinum can also occur, albeit much more rarely. The latter complications were reported for the first time in 1953 and have since that time been reported only very infrequently . Although the complications of cervical subcutaneous emphysema with pneumomediastinum after tonsillectomy reflect the inadvertent introduction of air, the passage of air to the mediastinum and subcutaneous tissues has rarely been observed directly. We experienced a case in which the passage of air was radiologically and histopathologically apparent. We report this case and also provide a literature review.
2
Case
A 36-year-old healthy woman who suffered frequently from tonsillitis was admitted for tonsillectomy. The preoperative physical examination revealed no other abnormalities. Tonsillectomy was performed under general anesthesia with orotracheal intubation. The tonsils were removed by monopolar electrodissection, and hemostasis was achieved by bipolar cautery. There was little bleeding, but the dissection was difficult because of the adhesion of the tonsils to the tonsillar bed.
On the first postoperative day, the patient complained of pain in the submandibular area. A physical examination revealed right facial and neck swelling and crepitus. Inspection of the tonsillar fossa revealed a deep defect, but a mucosal tear was not observed ( Fig. 1 ). The patient had no signs of airway, ventilator, or hemodynamic embarrassment. Apart for several coughs in the postoperative period, there were no special events.
A chest x-ray revealed subcutaneous emphysema and pneumomediastinum and a computed tomographic scan also showed subcutaneous emphysema of the face and neck along with a large volume of air and a muscle defect in the right tosillar fossa. The emphysema extended superiorly to the soft palate and tracked inferiorly into the upper mediastinum along the parapharyngeal and retropharyngeal spaces ( Fig. 2 ). Based on these observations, the patient was diagnosed with cervical subcutaneous emphysema and pneumomediastinum that developed after tonsillectomy. A combination of broad-spectrum antibiotics was injected intravenously, and the patient was restricted to bed-rest and instructed to refrain from coughing and vomiting.
Two days after surgery, the patient showed mild fever, and plain radiographs revealed pneumonia and pleural effusion. Four days after surgery, the fever was no longer detected, and chest plain radiography revealed a substantial decrease in the pneumonia and pleural effusion. In addition, the subcutaneous emphysema in the neck area was found to have decreased substantially. Histopathological examination of the 2 resected specimens revealed the presence in the right tonsil specimen of muscles along with the tonsil. The patient was discharged with a good prognosis a week after surgery. Up until now, follow-up visits have found her to be in good health without any special findings.
2
Case
A 36-year-old healthy woman who suffered frequently from tonsillitis was admitted for tonsillectomy. The preoperative physical examination revealed no other abnormalities. Tonsillectomy was performed under general anesthesia with orotracheal intubation. The tonsils were removed by monopolar electrodissection, and hemostasis was achieved by bipolar cautery. There was little bleeding, but the dissection was difficult because of the adhesion of the tonsils to the tonsillar bed.
On the first postoperative day, the patient complained of pain in the submandibular area. A physical examination revealed right facial and neck swelling and crepitus. Inspection of the tonsillar fossa revealed a deep defect, but a mucosal tear was not observed ( Fig. 1 ). The patient had no signs of airway, ventilator, or hemodynamic embarrassment. Apart for several coughs in the postoperative period, there were no special events.
A chest x-ray revealed subcutaneous emphysema and pneumomediastinum and a computed tomographic scan also showed subcutaneous emphysema of the face and neck along with a large volume of air and a muscle defect in the right tosillar fossa. The emphysema extended superiorly to the soft palate and tracked inferiorly into the upper mediastinum along the parapharyngeal and retropharyngeal spaces ( Fig. 2 ). Based on these observations, the patient was diagnosed with cervical subcutaneous emphysema and pneumomediastinum that developed after tonsillectomy. A combination of broad-spectrum antibiotics was injected intravenously, and the patient was restricted to bed-rest and instructed to refrain from coughing and vomiting.
