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Extensive subcutaneous emphysema and pneumomediastinum on the dental chair
  1. Mahdi Malekpour
  1. Geisinger Medical Center, Danville, Pennsylvania, USA
  1. Correspondence to Dr Mahdi Malekpour, Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA; mmalekpourghorbani{at}geisinger.edu

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Clinical Introduction

A 32-year-old woman was seen at the dentist’s office for pain associated with a broken molar tooth for over 6 months. During the use of a high-speed air-turbine drill, she suddenly developed severe neck pain and swelling. Procedure continued, which led to progression of her symptoms, including shortness of breath, for which the patient was sent to the emergency department. She was found to be afebrile, with stable vital signs and saturation of 100% on room air. She did not have any complaints of difficulty swallowing. Initial chest X-ray is shown in figure 1.

What is the most likely diagnosis?

  1. Allergic reaction to medication.

  2. Oesophageal injury.

  3. Airway injury.

  4. Dental drill injury.

Answer: D

Initial chest X-ray showed pneumomediastinum (figure 2). Further CT images better showed subcutaneous emphysema and pneumomediastinum (figures 3–4). Allergic reaction would cause soft tissue swelling and not free air. She did not have any signs and symptoms of airway compromise nor difficulty swallowing; therefore, oesophageal and airway injuries are unlikely. She was placed on a 7-day course of amoxicillin–clavulanate (875–125 mg every 12 hours), was observed overnight, and her broken tooth extracted and discharged on the following day. At 2 weeks of follow-up, the patient had no complaints and no subcutaneous emphysema. Conventional high-speed air-turbine drill rotates at about 250 000 RPM and generates about 5 bars of air pressure. Roots of the first three molars are in direct communication with the submandibular and sublingual space. Air that is inserted into the soft tissue at this speed can dissect along the natural planes of the head and neck, extending into the mediastinum.1 No infectious source was suspected nor any organism was known to act at this speed; therefore, empiric short-term prophylactic antibiotic coverage and extraction of the broken tooth was completed.

Figure 2

Chest X-ray with arrows marking the pneumomediastinum.

Figure 3

Axial CT image of the neck showing extensive air in soft tissue (arrows).

Figure 4

Sagittal CT image of the chest with arrows showing air in the neck and behind the sternum.

Reference

Footnotes

  • Contributors MM was involved in the care of patient, acquired consent, and wrote the draft and final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.