FACIAL EMPHYSEMA DURING ZYGOMATIC BONÉ FRACTURE
REDUCTION PROCEDURE
893
FACIAL EMPHYSEMA DURING ZYGOMATIC
BONE FRACTURE REDUCTION PROCEDURE
ENFISEMA FACIAL DURANTE O PROCESSO DE
REDUÇÃO DE FRATURA ZIGOMÁTICA
Daniel Luiz Gaertner ZORZETTO **
Clóvis MARZOLA ***
Marcos Maurício CAPELARI **
Marcelo Rodrigues AZENHA *
Lucas CAVALIERI-PEREIRA *
Luiz Gustavo MASSARIOLI-OLIVEIRA *
__________________________________________
* Residents of Oral and Maxillofacial Surgery, Division of Oral and Maxillofacial Surgery, Base
Hospital , Bauru, São Paulo, Brazil.
** Associate Professor of Oral and Maxillofacial Surgery, Division of Oral and Maxillofacial Surgery,
Base Hospital, Bauru, São Paulo, Brazil.
*** Oral and Maxillofacial Surgery retired Titular professor, Division of Oral and Maxillofacial
Surgery, São Paulo University, USP, Bauru, São Paulo, Brazil.
FACIAL EMPHYSEMA DURING ZYGOMATIC BONÉ FRACTURE
REDUCTION PROCEDURE
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ABSTRACT
During surgical procedures different accidents/complications may
occur with emphysema been one of them. It happens when air is introduced into
tissues under positive pressure.
The treatment of surgical emphysema is
conservative and antibiotic therapy is advocated, with complete recovery usually
been observed. Third molars extraction and endodontic therapy are the most
common relates in neck/face region. This paper describes a case of facial
emphysema developed during a zygomatic bone fracture stabilization realized under
general anesthesia. The tissue dissection was probably caused by a perforation
presented at nasal traqueal canulla with air reaching the facial space from the
zygomatic fracture site. It is important to general dentistry to know how to diagnosis
and to treat facial emphysema.
RESUMO
Durante um processo cirúrgico diferentes tipos de acidentes e ou
complicações podem ocorrer como um enfisema. Essa alteração acontece quando o
ar é introduzido no interior dos tecidos sobre pressão positiva. O tratamento do
enfisema cirúrgico é sempre conservador e com antibioticoterapia, com a completa
reversão do quadro sendo conseguida. Extração de terceiros molares e terapia
endodôntica são os relatos mais comuns encontrados na região do pescoço e da face.
Este trabalho descreve um caso de enfisema facial desenvolvido durante a redução de
uma fratura zigomática realizada sobre anestesia geral. O tecido dissecado foi
provavelmente causado por uma perfuração apresentada na cânula naso traqueal com
o ar ocupando o espaço facial do lugar da fratura zigomática. É importante para o
clínico geral saber qual o diagnóstico e o tratamento do enfisema facial.
Uniterms: Double lip; Hyperplasia; Syndrome of Ascher.
Unitermos: Lábio duplo; Hiperplasia; Síndrome de Ascher.
INTRODUCTION
Post
surgical
subcutaneous
emphysema
(SE)
and
pneumomediastinium were first described (TURNBULL, 1900) after a tooth
extraction when the patient blew a bugle. Since then, different cases have been
reported (SANDLER; LIBSHITZ; MARK, 1975; SNYDER; ROSENBURG,
1977; HOROWITZ; HIRSHBERG; FREEDMAN, 1987; NOBLE, 1972;
CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991; HEYMAN;
BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA; NESHA, 2001;
RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and
FACIAL EMPHYSEMA DURING ZYGOMATIC BONÉ FRACTURE
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VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). Emphysema is
a well known complication that arises when air is introduced into soft tissues by a
positive pressure and is described in facial region following restorative dentistry
treatment, tooth extraction and periodontal surgery (SANDLER; LIBSHITZ;
MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG;
FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST;
HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et
al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et
al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES
R. R. et al., 2006). This type is the most common one, however, it may reach the
deep anatomic spaces such as the mediastinal space, the peritoneum,
pterygomandibular, parapharyngeal, retropharyngeal and deep temporal spaces
(SANDLER; LIBSHITZ; MARK, 1975; HOROWITZ; HIRSHBERG;
FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST;
HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et
al., 2000 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006).
During the clinical exam subcutaneous crepitation may be felt and functional
limitation is also seen at the area. The treatment of surgical emphysema is
conservative with antibiotic therapy been ministrated (HOROWITZ;
HIRSHBERG; FREEDMAN, 1987; GUEST; HENDERSON, 1991; PENNA;
NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004 and
MARZOLA, 2005).
This report describes a case of facial SE that occurred during a
zygomatic bone surgical reduction procedure in a 13-year-old boy.
CASE REPORT
A 13-year-old boy presented to the Oral and Maxillofacial Surgery
Department, Base Hospital, Bauru, São Paulo, Brazil with a complain of numbness
in the left facial region and dyplopia. He reported of been hit during a soccer game 2
days ago. At clinical and radiographic exams was observed a zygomatic bone
fracture classified as type 6 (DINGMAN, 1964).
Under general anesthesia at Base’s Hospital surgery facilities, a
temporal region approach was made (GILLIES; KILLER; STONE, 1927) in
association with an infra orbital incision to reach the left inferior orbital rim to fix the
zygomatic bone with titanium plate and screws devices.
During the fixation procedure severe SE was noted in the left facial
region (Figure 1).
No anesthesia failure was presented neither the electrocardiography
showed any alteration on ST-T segment.
The surgery was completed and antibiotics were administered for
seven days after surgical procedure.
Anti-inflammatory and analgesics medication was prescribed also.
The post-operative course was uneventful with totally recovered of the
emphysema after 6 days with no alterations noted (Figure 2).
FACIAL EMPHYSEMA DURING ZYGOMATIC BONÉ FRACTURE
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Figure 1 – Subcutaneous facial emphysema after the surgical procedure.
Figure 2 – Post-operative facial appearance after 14 days.
DISCUSSION
Emphysema is a well-known complication following surgical
procedures such as restorative dentistry, periodontal surgery and oral and
maxillofacial surgery (SANDLER; LIBSHITZ; MARK, 1975; SNYDER;
ROSENBURG, 1977; HOROWITZ; HIRSHBERG; FREEDMAN, 1987;
NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991;
HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA;
NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004;
MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et
al., 2006). The advent of the air rotor drill increased this situation that arises when
air is introduced into soft tissues under positive pressure. Almost 8% of patients who
entered an emergency room with paranasal sinus fracture an emphysema situation
can be observed (BRASILEIRO; CORTEZ; ASPRINO, 2005). In this case, the
patient did not present a SE during the first evaluation, but developed this
complication at surgical procedure.
Different cases of emphysema following tooth extraction or dental
therapy are reported, but none describing surgical emphysema developed during a
facial bone reduction procedure. The emphysema showed in this paper did not
extend to the deep spaces as the mediastinal one (SANDLER; LIBSHITZ; MARK,
1975; HOROWITZ; HIRSHBERG; FREEDMAN, 1987; NOBLE, 1972;
CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991 and
HEYMAN; BABAYOF, 1995) and was not caused by an air turbine dental hand
FACIAL EMPHYSEMA DURING ZYGOMATIC BONÉ FRACTURE
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piece (SANDLER; LIBSHITZ; MARK, 1975; HOROWITZ; HIRSHBERG;
FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST;
HENDERSON, 1991; SEKINE; IRIE; DOTSU et al., 2000; RIBEIRO JR;
GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and VALLARELLI;
SOUZA-SILVA; MARQUES R. R. et al., 2006) or during a dental treatment
(TURNBULL, 1900; SNYDER; ROSENBURG, 1977; HEYMAN; BABAYOF,
1995; PENNA; NESHA, 2001; MARZOLA, 2005 and VALLARELLI; SOUZASILVA; MARQUES R. R. et al., 2006). The perforations to fix the titanium screws
and the plate after the zygomatic bone reduction were made by an electrical drill
without the use of any equipment that release under pressure air like a nitrogen
cylinder.
Most cases of emphysema occur during surgery procedure or within
the first post operative hour and the treatment consist in the use of broad-spectrum
antibiotics coverage, anti-inflammatory and pain relieve medication. Air that entered
the soft tissues has a high probability to be contamined (SANDLER; LIBSHITZ;
MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG;
FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST;
HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et
al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et
al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES
R. R. et al., 2006). In our case the emphysema occurred during the surgical
procedure disappearing at 14° post-operative day and a second generation
cephalosporin were used during 7 days after the surgery.
The clinical signs and symptoms of emphysema include regional
swelling, dyspnea, dysphagia, dysphonia, weaknesses, crepitus on palpation,
electrocardiography alteration and minimal pain (HOROWITZ; HIRSHBERG;
FREEDMAN, 1987 and RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004).
Radiographic exams showed a soft tissue expansion with radiolucids areas near to
the soft tissues (RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004). Regional
swelling, crepitus on palpation and no pain was observed at the present study.
Since emphysema is caused by the introduction of air under pressure
into the tissues there is a doubt about the origin of the emphysema related in this
case. The most acceptable hypothesis is that the nasal traqueal canulla could have a
small perforation and during the surgical procedure the air was introduced to
maxillary sinus and reached superficial facial space from the zygomatic fracture site
causing the facial swelling.
CONCLUSION
The report showed classical emphysema of facial spaces during a
zygomatic fracture surgery procedure.
The emphysema is an uncommon
complication but it is possible to occur during an oral and maxillofacial surgery. Its
characteristics should be observed to not mistake with post operative edema or
rapidly expanding hematoma. We believe that patients with emphysemas symptoms
should be routinely seen to exclude the possibilities of further complications.
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* According with ABNT norms.
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