Neumomediastino espontáneo en pacientes COVID-19. Serie de casos / Spontaneous pneumomediastinum in COVID-19 patients. Case series

Resumen El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

Abstract Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea / Massive subcutaneous emphysema, nemotórax voltage and pneumomediastinum after percutaneous tracheostomy

Mujer de 68 años que ingresa en la Unidad de Cuidados Intensivos por shock séptico. En el posoperatorio la paciente se mantiene inestable y se decide realizar traqueotomía percutánea (TP) por intubación prolongada. Al inicio la paciente presenta un enfisema subcutáneo que progresa hasta convertirse en masivo. Se realiza TC torácico donde se observa pérdida de la morfología habitual de la pared posterior traqueal con solución de continuidad. Tras revisión mediante traqueobroncoscopía se decide colocar cánula de traqueotomía larga para dejar la lesión proximal al neumotaponamiento y así evitar la fuga de aire. Desde la colocación de la nueva cánula, la paciente presenta una disminución progresiva del enfisema hasta su total resolución. La TP es un procedimiento seguro que se realiza con mucha frecuencia en los servicios de medicina intensiva, sin embargo, no está exenta de complicaciones. En la revisión de Powell y cols describen las complicaciones de la TP destacando la inserción peritraqueal, la hemorragia, las infecciones de la herida, el neumotórax y la muerte. El rango de complicaciones en la literatura oscila entre 3% y 18%. Además, no se encuentran diferencias significativas respecto a las complicaciones entre la TP y la técnica abierta.

A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.

Subcutaneous emphysema during third molar surgery: a case report

Extraction of third molars is the most common surgical procedure performed in oral surgery on a daily basis and, despite surgical skills and expertise, complications may occur. Complications observed during or after third molar removal may include pain, swelling, bleeding, infection, sinus perforation and nerve damage. Fortunately, with a proper management and a good surgical technique, the incidence of such events is low. Subcutaneous emphysema associated with dental extraction occurs when the air from the high-speed dental handpiece is forced into the soft tissue through the reflected flap and invades the adjacent tissues, leading to swelling, crepitus on palpation and occasionally spreading through the tissue spaces of the fascial planes. Although rare, iatrogenic subcutaneous emphysema can have serious and potentially life-threatening consequences. Care should be taken when using air-driven handpieces. The access of air into the facial tissues is not limited to tooth extractions, but may also occur through other portals of entrance, such as endodontically treated teeth, periodontium and lacerations of intraoral soft tissues. When subcutaneous emphysema occurs, it must be quickly diagnosed and properly managed to reduce the risk of further complications. This report presents a case of subcutaneous emphysema occurred during extraction of a mandibular third molar extraction with the use of an air turbine handpiece. Case management is described and issues relative to the diagnosis and prevention of this surgical complication are discussed.

A extração de terceiros molares é o procedimento cirúrgico mais comum na prática diária em cirurgia oral, e complicações podem ocorrer a despeito da habilidade e experiência do cirurgião. Complicações observadas durante ou após extração de terceiros molares podem incluir dor, edema, sangramento, infecção, perfuração de seio e dano nervoso. Felizmente, a incidência de tais eventos é baixa quando se emprega conduta adequada e boa técnica cirúrgica. O enfisema subcutâneo associado à extração dentária ocorre quando o ar da turbina de alta rotação é forçado para dentro dos tecidos moles através de um retalho rebatido e invade os tecidos adjacentes, causando edema, crepitação à palpação, e eventualmente espalhando-se pelos espaços teciduais dos planos fasciais. Embora seja raro, o enfisema subcutâneo iatrogênico pode ter conseqüências sérias e com risco de morte. É necessário ter cuidado com o uso de turbinas de alta rotação durante a realização de procedimentos cirúrgicos orais. A penetração de ar nos tecidos faciais não está limitada às extrações dentárias, e pode ocorrer também por outras vias de acesso, tais como dentes tratados endodonticamente, periodonto e lacerações de tecidos moles intraorais. Quando ocorre, o enfisema subcutâneo deve ser diagnosticado rapidamente e tratado adequadamente para diminuir o risco de outras complicações. Este relato apresenta um caso de enfisema subcutâneo ocorrido durante a extração de um terceiro molar inferior com emprego de turbina de alta rotação. O manejo do caso é descrito e os aspectos relacionados ao diagnóstico e à prevenção desta complicação cirúrgica são discutidos.

Detección rápida de neumotórax mediante efast en pacientes con trauma múltiple / Rapic detection of pneumotorax through efast in patients with multiple trauma

El propósito de este estudio es evaluar la eficacia para diagnósticar apropiadamente neumotórax en pacientes con trauma multisistémico mediante eFAST realizado por cirujanos y residentes de cirugía en la Unidad de Trauma-Shock Hospital General del Sur "Dr. Pedro Iturbe", Maracaibo. Se realizó un estudio prospectivo, observacional, descriptivo y transversal, durante el período comprendido entre enero 2008 y marzo 2009. Las variables estudiadas fueron: edad, sexo, mecanismo del trauma, lesiones asociadas estabilidad hemodinámica, tiempo de ralización de radiografías y el eFAST, sensibilidad, especificidad, valor predictivo negativo y positivo del eFAST con relación a las radiografías de tórax. Imágenes complementarias y conducta seguida. Un total de 169 eFAST fueron realizados en un período de 14 meses 36 casos (21,3%) fueron positivos para neumotórax, la edad promedio fue 32,67 ± 14,3 (15-84), el sexo masculino prevaleció con un 142 casos (84%), Mecanismo de trauma: colisión 84 casos (49,7%), trauma directo 22 casos (13%), lesiones asociadas: abdomen 59 casos(134,9%), 144 casos (85,2%) se encontraban hemodinámicamente estables 144 casos (85,2%). El tiempo de realización de las radiografías tuvo un promedio de 40,17 minutos ± 12,5 (20-90), el eFAST 2,94 ± 0,5 (2-5), eFAST obtuvo una sensibilidad de un 92,11% y una especificación de 99,24% mediante la combinación del análisis de la linea pleural en tiempo real y el signo de la estratósferas/arena de playa en modo movimiento/tiempo para diagnósticar neumotórax en pacientes con trauma torácico. El eFAST es una herramienta confiable que permite diagnósticar rápidamente neumotórax en pacientes con trauma multiple, portátil, facit, con una precisiòn diagnóstica comparables con la radiografía del tórax y que aporta información fundamental que permite orientar los esfuerzos del equipo quirúrgico en el manejo de estos pacientes.

The purpose of this study is to assess the effectiveness to properly diagnose pneumothorax in patients with multisystem trauma through eFAST performed by surgeons and surgery residents at the Trauma-Shock Unit of the Hospital General del Sur "Dr. Pedro Iturbe", Maracaibo. There was performed a prospective,observational, descriptive and cross-sectional study, during the period between January 2008 and March 2009, the studied variales were age, sex, mechanism of trauma, injury associated, hemodynamic stability, time realization of Rx and eFAST, sensitivity, specificity, positive and negative predictive value of the eFAST in relation to the chest X ray, additional images and conduct. A total of 169 eFAST were made in a period of 14 months 36 cases (21.3%) were positive for pneumothorax, the average, age was 32, 67 ± 14,3 (15-84), male prevailed with a 142 cases (84%). Mechanism of trauma 84 collisión cases (49.7%), trauma direct 22 cases (13%), injuries associated: abdomen 59 cases (34.9%), 144 cases (85.2%) were hemodynamically stable 144 cases (85.2%). Time of realization of X rays averaged 40, 17 minutes ± 12, 5 (20-90), eFAST 2,94 ± 0,5 (2-5), eFAST obtained a sensitivity of 92,11% and a specificity of 99,24 through a combination of the analysis of the pleural line in real time and the sign of the stratosphere/sand beach in motion/time mode to diagnose pneumothorax in patients with chest trauma. The eFAST is a reliable tool chat allows to quickly diagnose pneumothorax in patients with multiple trauma; portable, easy, accurately diagnosed comparable with chest X rays and that provides fundamental information allowing to guide the efforts of the surgical team in the management of these patients.

Pneumomediastinum, pneumothorax, and subcutaneous emphysema due to duodenal ulcer

The presence of pneumothorax, pneumomediastinum, or cervical subcutaneous emphysema due to perforated duodenal ulcer is a rare presentation. We report a 23-year man who showed bilateral cervical subcutaneous emphysema, pneumomediastinum, and pneumothorax with no respiratory abnormality. He was found to have active duodenal ulcers, but no detectable pneumoperitoneum or duodenal leal. A sealed perforation from the duodenal ulcers was suspected, and he fully improved after conservative management

Subcutaneous emphysema after ultrasonic treatment: a case report / Enfisema subcutáneo posterior a la higienización con ultrasonido: reporte de un caso

Subcutaneous emphysema is a rarely disease seen in dentistry. It can be caused by the inadvertent introduction of air into the soft tissue during oral cavity procedures. In this paper, we present a case that developed asubcutaneous emphysema in genial, submandibular and eyelid area, in a middle-aged woman after treatment with ultrasonic method.

El enfisema subcutáneo es una patología vista con poca frecuencia en odontología. Puede ser causada por la introducción involuntaria de aire en los tejidos blandos durante los procedimientos efectuados en la cavidad oral. En este trabajo, se presenta un caso de enfisema subcutáneo geniano, palpebral y submandibular, en una mujer de mediana edad después de un tratamiento de higienización con un equipo de ultrasonido.

Extensive subcutaneous emphysema due to colonic perforation following colonoscopy

During colonoscopy, subcutaneous emphysema may occur as a result of colonic perforation into retroperitoneal area. In this report, a 54-year-old woman with sigmoid colon perforation following colonoscopy is described. Subcutaneous emphysema was the first manifestation of the perforation in this case. Initially, the patient received supportive, non-surgical treatment, but due to development of acute abdominal signs and symptoms in later stages, the patient underwent surgical treatment

Pneumoparotitis with subcutaneous emphysema.

We report an adolescent with recurrent bilateral parotitis with pneumoparotitis and subcutaneous emphysema due to self pneumoinsufflation by a Valsalva like maneuver. Investigations for recurrent parotitis did not yield any clue. His la belle indifference, prolonged school absence and the presence of sibling rivalry helped us identify the psychological cause.

Surgical emphysema and pneumomediastinum following mastoidectomy.

Surgical emphysema and pneumomediastinum are rare complications of mastoidectomy probably resulting from the use of a compressed air-powered mastoid drill. Early diagnosis and appropriate management according to the severity is vital.

Enfisema subcutâneo, pneumotórax e pneumomediastino após tonsilectomia / Emphysema subcutaneous, pneumothorax and pneumomediastinum after tonsillectomy

Várias complicações podem estar relacionadas a procedimentos cirúrgicos na área de cabeça e pescoço. O pneumomediastino, pneumotórax e enfisema subcutâneo estão descritos em menor número de casos, em relação às demais complicações. Nesses procedimentos, constata-se importante o cuidado com a técnica cirúrgica, evitando manobras cirúrgicas agressivas, além de parcimônia no uso de máscaras de oxigênio sob pressão positiva e intubação. Este estudo relata um caso de enfisema subcutâneo, pneumotórax e pneumomediastino, com aparecimento 48 horas após tonsilectomia palatina, e discute possíveis mecanismos, morbidade, formas de prevenção e tratamento

Several complications can be related to surgical approaches of the head and neckareas. Subcutaneous emphysema, pneumothorax and pneumomediastinum are described in a small number of cases, among others. In these surgeries, a careful surgical technique approach is of utmost importance, and aggressive surgical maneuvers should be avoided.Caution should be taken with the use of oxygen masks for positive pressure ventilation during anesthesia recovery and intubation. This study reports a case of pneumomediastinum, pneumothorax and subcutaneous emphysema that appeared 48 hours after palate tonsillectomy and discusses possible mechanisms, morbidity, ways of prevention and treatment

Cervico-facial emphysema following endotracheal intubation: a case report

Subcutaneous surgical emphysema post-endotracheal intubation is a very rare complication. Few cases were reported worldwide. We reported one case, which was a 53-year-old female who developed cervico-facial subcutaneous emphysema after endotracheal intubation for nasopharyngeal tumor biopsy

Laparoscopic Myomectomy for Large Myomas

The aim of this study was to assess the feasibility and efficacy of laparoscopic myomectomy (LM) for large myomas. A subpopulation of 51 patients with myomas 8 cm or larger in diameter was selected from 155 patients who underwent LM at Kangbuk Samsung Hospital from July 2003 to November 2006. The mean age of the patients was 34.9+/-5.6 yr, mean parity was 0.6+/-0.9, and 8 patients had a previous operative history. The most common operative indication was a palpable abdominal mass (24 patients, 47%). The mean operating time was 85.6+/-38.9 min, and the mean diameter of the largest myoma was 9.3+/-1.8 cm. The mean change in hemoglobin concentration was 2.1+/-1.2 g/dL. Histopathological diagnosis included 49 patients of leiomyoma (96.1%) and 2 patients of leiomyoma with adenomyosis (3.9%). Postoperatively, a transfusion was done in 7 patients, and a case of subcutaneous emphysema was noted. None of the operations was switched to laparotomy. With the newly-developed screw and the port placement system that was modified from the Choi's 4-trocar method to obtain better surgical vision, LM of large myomas proved to be one of the efficient and feasible methods.

Percutaneous dilational tracheostomy: an initial experience in community based teaching hospital.

Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. OBJECTIVE: To report the analysis of our experience with percutaneous dilation tracheostomy. STUDY DESIGN: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. METHOD: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. RESULT: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. CONCLUSION: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.

Strangulated femoral hernia presenting as parietal wall emphysema.

Surgical emphysema of abdominal and thoracic wall, along with features of intestinal obstruction, has not been reported as a complication of strangulated femoral hernia. We report a 31-year-old woman with such a presentation.

Enfisema subcutâneo pós-amigdalectomia: relato de caso

JUSTIFICATIVA E OBJETIVOS: A amigdalectomia é considerada um procedimento relativamente seguro. O objetivo deste relato foi mostrar uma complicação rara desta cirurgia, o enfisema subcutâneo. RELATO DO CASO: Paciente do sexo masculino, 25 anos, com amigdalite recorrente e hipertrofia de cornetos. Foi submetido a amigdalectomia e turbinectomia sob anestesia geral com intubação orotraqueal. A operação transcorreu sem intercorrências. Na sala de recuperação pós-anestésica (SRPA) o paciente agitou-se, apresentando grande esforço físico. Quatro horas após a cirurgia, notou-se edema crepitante e depressível no pescoço e na região parotídea esquerda, característico de enfisema subcutâneo. A tomografia computadorizada mostrou a existência de ar nas regiões malar e cervical (principalmente à esquerda), atingindo até o mediastino superior. Não houve obstrução das vias aéreas e o estado geral do paciente permaneceu estável. Teve alta hospitalar no dia seguinte e foi acompanhado no ambulatório. O enfisema regrediu totalmente após 10 dias. CONCLUSÕES: O enfisema subcutâneo é uma complicação rara da amigdalectomia, ocorrendo quase sempre após dissecções profundas da mucosa faríngea, quando se cria interface porosa que proporciona a entrada do ar. O aumento da pressão nas vias aéreas superiores pode contribuir para o problema.

Enfisema subcutâneo e pneumomediastino após amigdalectomia: relato de caso / Onset of subcutaneous emphysema and pneumomediastinum after tonsillectomy: a case report

Várias complicacões podem estar relacionadas a procedimentos cirúrgicos na área de cabeca e pescoco. Entre elas, o pneumomediastino, pneumotórax e enfisema subcutâneo ocorrem raramente. Relatamos o caso de uma paciente submetida a tonsilectomia palatina que evoluiu com enfisema subcutâneo da região cervical, torácica e pneumomediastino. Em cirurgias de tonsilas palatinas devem ser observados cuidados com a intubacão, uso de máscara sob pressão positiva com oxigênio na recuperacão anestésica, atos cirúrgicos intempestivos e uso de aparelhos que proporcionem lesão excessiva na loja tonsiliana a fim de se evitar as complicacões descritas.