This document discusses subcutaneous emphysema, which occurs when air is introduced into the subcutaneous fascia, causing soft tissue swelling. It can arise during dental procedures when compressed air enters tissues through patent canals or gingival sulci. Common symptoms include localized swelling, crepitus, and discomfort. While usually benign and self-resolving, air can occasionally spread to dangerous areas if not properly managed. Prevention involves avoiding direct air use and instead drying canals with paper points.

1. SUBCUTANEOUS
EMPHYSEMA

2. INTRODUCTION
 Emphysema - Greek word, ‘whick’ - ‘to
blow in.’
 Subcutaneous emphysema of the
head,neck, and thorax is caused by the
introduction of air into the fascial planes
of the connective tissue.
 Because of the looseness of the
connective tissue and its distensible
walls, air can accumulate in these
crevices and convert them into spaces of
considerable size.

3.  Periorbital emphysema is
subcutaneous emphysema that arises
when air is introduced into the
periorbital tissues.
 Subcutaneous emphysema arises
when air is forced, under pressure, into
the subcutaneous fascia leading to a
sudden
onset of soft tissue swelling

4. compressed air {air syringe}
patent canal
periapical tissue
labial cortical plate,
periorbital space.
 Periorbital space - low tissue resistance
 air accumulates readily in this space -
sudden onset of the swelling of upper
and lower eyelids.

5. Pressurised air
labial sinus tract gingival sulcus
periorbital emphysema

6. CAUSES
 During apical surgery, air from a high-
speed drill can lead to air emphysema.
 Blowing the nose vigorously
 Habitual performance of Valsalva
manoeuvre
 Playing a wind instrument after an
extraction
 Trauma
 Vigorous coughing

7.  Surgical procedures during which air is
introduced into soft tissue spaces.
 Endodontic origin occur following the
use of air-driven handpieces,
use of H2O2 irrigation
use of air syringe to dry the canal
 Any time a stream of air is directed
toward exposed soft tissues, the
potential for a problem exists.

8. Signs & symptoms
 Immediate
 Local soft skin-
coloured swelling
without redness
 Crepitus
 Local discomfort
 Subsequent
 Diffuse swelling
 Local erythema
 Pyrexia and Pain

9.  Hayduk et al. regard crepitus as
pathognomonic of tissue space emphysema
which allows one to quickly rule out
anaphylactic reaction.
 Dysphagia
 Dyspnea: Migration of air into the neck region
could cause respiratory difficulty, and
progression into the mediastinum could
cause death.

10.  Pain is a variable feature of
subcutaneous emphysema and
patients usually complain of
discomfort due to soft tissue
distension.
 Unlike irrigant extrusion reactions,
tissue space emphysema remains in
the subcutaneous connective tissue
and usually does not spread to the
deep anatomic spaces

12.  Alarming to the patient and clinician.
 Rarely,serious complications such as
pneumomediastinum and airway
compromise are seen.
 On rare occasions trapped air can
spread along the fascial planes to the
periorbital,
mediastinal,parapharyngeal,
pericardial and thoracic spaces
causing serious and life threatening
complications.

13.  Its occurrence in conjunction with
a dental procedure was first reported
more
than a hundred years ago when Turnbull
extracted the premolar of a musician who
blew his bugle immediately after
extraction.

14. MANAGEMENT
 Usually a benign condition that
resolves over 3–10 days as the gas is
resorbed into the blood stream for
eventual excretion via the lungs
 Supportive management

15.  Most authors, however, recommend a
course of prophylactic antibiotics,
most commonly penicillin and
analgesics for 10 days to prevent
secondary infection from
dissemination of oral flora along the
emphysematous tract
 Cough suppressants may be
prescribed to prevent further air entry
into the fascial planes

16.  A follow-up appointment within 48
hours is imperative to monitor
resolution and signs of infection
 Severe cases, hospitalization may be
necessary for observation and follow-
up radiographs

17.  Administration of 100% oxygen via a
non breather mask can hasten the
resolution of emphysema because
oxygen, which replaces the air, is more
readily absorbed.
 Nitrous oxide sedation: the
administration of nitrous oxide should
be discontinued because the gas will
diffuse into the air spaces and increase
the volume of trapped air.

18. PREVENTION
 Avoiding the use of direct
compressed air to dry root canals.
 Using remote exhaust handpieces or
electric motor driven ones.
 Avoiding the use of hydrogen
peroxide as a root canal irrigant.

19.  Using sterile cotton pellets and
endodontic paper points to dry root
canals.
 In surgical procedures, once a flap is
reflected, apical access can be made
with the slowspeed or high-speed
handpieces that do not direct jets of
air into surgery sites

20.  If the air syringe is to be used, Jerome
suggested horizontal positioning over
the access opening, to aid in drying
the canal.

21. CONCLUSION
 Subcutaneous emphysema is a rare but
potentially serious complication of root
canal treatment.
 Characterised by sudden onset of soft
tissue swelling, associated with crepitus,
during or shortly after the procedure.
 Introduction of compressed air into
tissue spaces via patent canals, sinus
tracts, soft tissue lacerations, or gingival
sulcus is the underlying mechanism in
most cases.

22.  Therefore, blowing compressed air
into root canals should be avoided and
paper points should be used to dry
root canals.
 The majority of cases are managed
conservatively and patients should be
advised as to the nature of
emphysema

23. REFERENCES
 A. Al-Qudah, F. Amin and Y. Hassona.
Periorbital emphysema during
endodontic retreatment of an upper
central incisor:a case report:British
Dental Journal nov 9 2013; 215(9)
 Dr. Abdul Hameed.Periorbital
emphysema unexpected
complication;Your Guide on the path
of Dentistry.

24.  Rakesh K. Yadav ,Anil Chandra ,A. P.
Tikku, K. K.Wadhwani,Promila verma;
Air emphysema - an in office
emergency: A case report.
 Lora Mishra, Swarnav Patnaik,
Sangram Patro, Nitai Debnath,
Satyaranjan Mishra. Iatrogenic
Subcutaneous Emphysema of
Endodontic Origin – Case Report with
Literature Review. Journal of Clinical
and Diagnostic Research. 2014 Jan,
8(1): 279-281

25.  Manon Paquette. Subcutaneous
Emphysema; Clinical Images in Oral
Medicine and Maxillofacial Radiology