DR NIKUNJR SHEKHADA (MBBS,MS GEN SURGERY,DNB CTS RESIDENT)

1. SUBCUTANEOUS EMPHYSEMA
BY DR NIKUNJ
(CTS RESIDENT STAR HOSPITAL)
(20/8/19)

2. SUBCUTANEOUS EMPHYSEMA
• Subcutaneous emphysema (SE) occurs when air gets into the tissues under the skin and in the
soft tissues.
• This usually occurs in the soft tissues of the chest wall or neck but can also occur in other parts of
the body
• Bullous emphysema can develop when a bulla, or air pocket, takes up space in your chest cavity
and disrupts normal lung function.
• Air forced into the interstitial tissues around the pulmonary vasculature travels back toward the
hilum, leading to pneumomediastinum, and this eventually tracts into the soft tissue of the neck,
face, and chest wall.

3. • The visceral space, which is continuous from the neck and mediastinum to the retroperitoneum originates
during embryological development.
• The visceral pleura overlies both lungs in addition to the organs in the mediastinum and encloses a space
known as the visceral cavity.
• The fascial planes connect cervical soft tissue to the mediastinum and retroperitoneum, and the spaces
between the fasciae permit aberrant air arising in any of these areas to spread.
• In patients with pneumomediastinum, air can flow from the peribronchial space to the neck, chest wall,
pleural cavity, mediastinum, retroperitoneum, pericardial cavity, pericardial space, and diaphragm.
• Although the body cavity is further divided into thoracic, abdominal, and pericardial cavities by the
pleuroperitoneal and pleuropericardial membranes, the cavities remain continuous throughout the visceral
space
• The visceral space, which is continuous from the neck and mediastinum to the retroperitoneum originates
during embryological development.
• The visceral pleura overlies both lungs in addition to the organs in the mediastinum and encloses a space
known as the visceral cavity.
• The fascial planes connect cervical soft tissue to the mediastinum and retroperitoneum, and the spaces
between the fasciae permit aberrant air arising in any of these areas to spread.
• In patients with pneumomediastinum, air can flow from the peribronchial space to the neck, chest wall,
pleural cavity, mediastinum, retroperitoneum, pericardial cavity, pericardial space, and diaphragm.
• Although the body cavity is further divided into thoracic, abdominal, and pericardial cavities by the
pleuroperitoneal and pleuropericardial membranes, the cavities remain continuous throughout the visceral
space

4. ETIOLOGY
• It can result from a number of processes,
• blunt or penetrating trauma,
• Rib fracture
• pneumo- thorax
• barotrauma
• cases of gas gangrene
• malignancy
• as a complication of surgical procedures and even spontaneous SE
• surgery around the esophagus.
• positive pressure ventilation for any reason and by any technique
• Air can leak out of the pleural space through an incision made for a thoracotomy to cause subcutaneous emphysema
• Dental procedure involving the use of compressed air equipment
• ruptured trachea while tracheal intubation
• esophageal perforation (Boerhaave syndrome)

5. • Hamman's syndrome, also known as Macklin's syndrome, is a syndrome of spontaneous
• subcutaneous emphysema
• pneumomediastinum
• barotrauma, where rupture of alveolar membranes causes a positive pressure gradient of air from the lungs
into the mediastinum (the Macklin effect)

6. ASTHMA
• In asthma exacerbations, pneumothorax and pneumomediastinum develop because the obstruction in the
minor airways leads to air-trapping and barotrauma of distal airways, and the subsequent alveolar rupture.
• The abrupt increase in intra-alveolar pressure is a phenomenon known as the Macklin effect.

7. SIGNS AND SYMPTOMS
• The most common and visible sign and symptom of SE is swelling around the neck accompanied with pain in
the chest.
• sore throat,
• aching neck,
• difficulty in swallowing,
• breathlessness,
• wheezing,
• and distension .
• It causes minimal symptoms, is not dangerous in itself, and requires no specific treatment .

8. • If it involves the deeper tissues of the thoracic outlet, chest, and abdominal wall, it will be a severe, stressful,
and lifethreatening condition.
• It can be complicated by restriction of full lung re-expansion and can lead to
• high airway pressure.
• severe respiratory acidosis.
• ventilator failure.
• pacemaker malfunction.
• airway compromise.
• and tension phenomena.

9. • Diagnosis is made by physical exam (crepitation on palpation) and radiological studies indicating air in the
involved area

10. • CT scans to verify subcutaneous emphysema
• oesophagogram

11. Chest computed tomography scans showing subcutaneous emphysema, pneumomediastinum (yellow arrows), and pneumothorax
on the left side (red arrow)

12. (1) base of the neck,
(2) all of the neck area,
(3) subpectoralis major area,
(4) chest wall and all of the neck area,
(5) chest wall, neck, orbit, scalp, abdominal wall, upper limbs, and scrotum

13. MANAGEMENT
• SE often presents a management dilemma
• Subcutaneous emphysema is often seen after thoracic surgical procedures. In most cases it is due to a leak from the lung
parenchyma and is self-limiting, requiring no specific treatment. Massive subcutaneous emphysema, however, should be
treated both to reduce discomfort and to prevent respiratory embarrassment.
• Its management should begin with a concerted effort to identify the offending cause of the subcutaneous dissection of air
• "Massive Subcutaneous Emphysema" which is quite uncomfortable and requires surgical drainage.

14. • Herlan et al reported success in managing four patients who developed massive spontaneous subcutaneous
emphysema with bilat- eral 3-cm infraclavicular incisions down to pectoralis fascia.
• Terada and Matsunobe reported using a trochar-type chest tube as a subcutaneous drain.
• Sherif and Ott the technique where they placed a drain in the tract dissected.
• A case report by Srinivas et al. describes the use of a modified microcatheter and active compressive
massage face downward and arms upward toward the catheter to facilitate drainage.

15. • Various approaches have been described, including the use of
• subcutaneous incisions,
• needles,
• drains, or
• cervical mediastinotomy .
• Two infraclavicular incisions
• Catheters can be placed in the subcutaneous tissue to release the air
• When subcutaneous emphysema occurs due to pneumothorax, a chest tube is frequently used
• bed rest, medication to control pain, and perhaps supplemental oxygen.
• oxygen may help the body to absorb the subcutaneous air more quickly.

16. • Grade5 of SE This patient was managed with two infraclavicular incisions
Classification and Management of Subcutaneous Emphysema: a 10-Year Experience
Manouchehr Aghajanzadeh & Anosh Dehnadi & Hannan Ebrahimi & Morteza Fallah Karkan & Sina Khajeh Jahromi & Alireza Amir Maafi & Gilda Aghajanzadeh
Association of Surgeons of India 2013

17. subcutaneous drain insertion.
Management of extensive subcutaneous emphysema with a subcutaneous drain Peter O’Reilly, Hua Kiat Chen & Rachel Wiseman
Christchurch Hospital, Christchurch, New Zealand

18. FLOWCHART OF MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX
British Thoracic Society pleural disease guideline 2012

19. THANK YOU