A case of subcutaneous emphysema following post-operative vomiting.

Sir,

Post-operative nausea and vomiting (PONV) is a common complication after general anaesthesia (GA), rarely it can cause life threatening complications such as subcutaneous emphysema (SCE), which can lead to airway compromise and necessitate intervention.[1] We describe a case of SCE neck, face and upper thorax, which developed 8 hours after Tympanoplasty under GA, following forceful vomiting. Early recognition and proper management is critical to prevent the progression.[2]

A 49-year-old lady diagnosed with left chronic suppurative otitis media was posted for tympanoplasty under GA. She was a hypertensive on treatment, with no other comorbid conditions. Pre-operative investigations were within normal limits. Following pre-medication with Ondansetron 4 mg intravenous (IV), Thiopentone was used for induction of anaesthesia. Atraumatic intubation with no. 7.5 cuffed oral endotracheal tube was facilitated with Suxamethonium 75 mg IV. Anaesthesia was maintained with oxygen, nitrous oxide, Halothane and Vecuronium, and controlled ventilation using Bain's circuit. Electrocardiogram, non-invasive blood pressure, Peripheral oxygen saturation and end tidal carbon dioxide were monitored. Vecuronium top up was given based on the requirement. After completion of the procedure, neuromuscular blockade was reversed, trachea extubated and shifted to post-anaesthesia care unit, where the patient was monitored for 2 hrs, then shifted to the ward.

About 8 hrs later in the ward, patient had a bout of cough and forceful vomiting following which she developed swelling of the face and neck. She complained of difficulty in breathing and change of voice in the supine position. On examination, patient had swelling of the face, neck and upper part of the chest bilaterally with crepitus over the swelling. Respiratory rate was 20/min, bilateral air entry present, vitals stable, and cardiovascular system clinically normal. She was shifted to Intensive care unit, administered oxygen by mask in propped up position and observed for respiratory and cardiac distress.

Neck X-ray showed air pockets in the anterolateral aspect, suggestive of SCE [Figure 1], air pockets were seen in the chest X-ray also.

Figure 1

Soft-tissue swelling in anterolateral aspect of neck with air pockets, suggestive of subcutaneous emphysema

General surgeon was informed in view of possible intervention. As nil per oral status was advised patient was maintained on IV fluids along with IV antibiotics, analgesics, antiemetics and steroids. No dyspnoea, oxygen desaturation or haemodynamic instability noted. Patient showed significant improvement in 48 hrs. She was allowed to take liquids orally on the 3rd day, and shifted to the ward on the 4th day. Patient made an uneventful recovery with conservative management, hence discharged from the hospital on 8th post-operative day.

SCE is a common occurance following surgeries such as chest surgery, laparoscopy, cricothyrotomy and pneumonectomy. On infrequent occasions, the condition can result from dental surgery, usually due to use of high-speed tools that are air driven.[2] It is a rare complication after endotracheal intubation, blowing of the nose and vomiting.[2] The cause for SCE after vomiting are possibly due to spontaneous rupture of esophagus, alveolar rupture, trauma to the trachea and hypo pharynx.[3]

This report describes the development of SCE after PONV with satisfactory response to conservative management. Change of voice is reported to herald airway compromise, but our patient did not develop this because inhalation of oxygen has helped in absorption of subcutaneous air quickly.[4] Nil per oral status was beneficial indicating that there could have been a small esophageal tear.[5] The role of antibiotics and steroids is unclear in these cases.[2]

Although cases of Boerhaave's syndrome, which is life threatening emergency (vomiting, chest pain and SCE) are reported in literature, isolated cases of SCE of the face and neck after PONV appear to be rare.[6]

The exact source of air could not be established as patient's relatives declined for further investigations such as computed tomography neck and thorax and oesophagogram. Small esophageal tear could have been the source of air leak. Root cause of the events was vomiting. Hence, there is a need to use antiemetics to prevent such complications in the post-operative period. Early recognition and proper management is of utmost importance to prevent the progression.