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428 LASER-INDUCED EMPHYSEMA

Oral Maxillofac Surg7:428-430, 2009

Cervicofacial Subcutaneous Emphysemaand Pneumomediastinum After Intraoral

Laser IrradiationTomoaki Imai, DDS, PhD,* Masahiro Michizawa, DDS, PhD,†

Emiko Arimoto, DDS, PhD,‡ Masaya Kimoto, DDS, PhD,§

and Yoshiaki Yura, DDS, PhD�

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ubcutaneous emphysema is a rare but well-knownomplication of dental procedures.1 It occurs mostommonly during tooth extraction2-6 or restorativeentistry7,8 due to the introduction of air into the subcu-aneous space through the head of a high-speed hand-iece. Less commonly, it also results from the irrigation ofoot canals9 or inappropriate usage of air-water syringes.10

Lasers are widely used in oral and dental surgery.11,12

ome devices for laser treatment are equipped with anir projection system to remove blood and vaporized orauterized tissue debris from the operation field. Inad-ertent handling of these devices as well as a high-speedandpiece or air-water syringe can therefore result inhe production of subcutaneous emphysema.13 We de-cribe a rare case of bilateral cervicofacial emphysemand pneumomediastinum occurring after CO2 laser irra-iation of a periapical lesion of an upper first premolar.

eport of a CaseA 49-year-old Japanese woman attended a private general

ental practitioner complaining of periapical mucosal swellingf the right upper first premolar covered with a porcelain-used metal crown. Because the patient refused consent to

*Clinical Fellow, Department of Oral and Maxillofacial Surgery,

aiseikai Senri Hospital, Osaka, Japan.

†Head, Department of Oral and Maxillofacial Surgery, Saiseikai

enri Hospital, Osaka, Japan.

‡Clinical Fellow, Department of Oral and Maxillofacial Surgery,

ennri Yorozu Hospital, Nara, Japan.

§Clinical Fellow, Department of Oral and Maxillofacial Surgery

II), Osaka University Graduate School of Dentistry, Osaka, Japan.

�Professor, Department of Oral and Maxillofacial Surgery (II),

saka University Graduate School of Dentistry, Osaka, Japan.

Address correspondence and reprint requests to Dr Imai: De-

artment of Oral and Maxillofacial Surgery, Saiseikai Senri Hospital,

-1 Tsukumodai, Suita, Osaka 565-0862, Japan; e-mail: hsc12@

otmail.com

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6702-0030$36.00/0

oi:10.1016/j.joms.2008.01.039 I

oth removal of the crown for an orthograde root canal treat-ent and endodontic surgery via a raised mucoperiosteal flap,

he dentist decided to incise the swollen mucosa with a CO2

aser for symptom improvement by pus discharge and cauter-zation of the lesion under local anesthesia. During irradiation,he patient complained of discomfort in the right side of theace, and subsequently developed bilateral cervicofacial swell-ng, a sense of pressure in the neck, dysphagia, and trismus.he was then transferred under paramedic care to Saiseikaienri Hospital.

On initial presentation, she was alert, well-perfused, andfebrile. Vital signs were normal, with a blood pressure of26/83 mm Hg, heart rate 70 beats per minute, respiratoryate 18 breaths per minute and oxygen saturation 99%. Shead no history of adverse reactions to medications, andxhibited no systemic signs associated with an allergic re-ction. She had difficulty in opening the right eyelids be-ause of the extensive cervicofacial swelling (Fig 1). Subcu-aneous crepitus was palpable bilaterally over the neck,heek, periorbital, and temporal areas. Intraoral examina-ion showed swelling around the irradiated alveolar mucosaf the right upper premolar but no mucosal swelling inther areas. Subcutaneous emphysema was clinically diag-osed. Dental x-ray showed a periapical radiolucent lesiont the right upper first premolar (Fig 2). Computed tomog-aphy (CT) of the thoracocervicofacial region showed wide-

IGURE 1. Clinical appearance on admission. Subcutaneous em-hysema resulted in extensive cervicofacial swelling.

mai et al. Laser-Induced Emphysema. J Oral Maxillofac Surg 2009.

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IMAI ET AL 429

pread emphysema from the infratemporal space to thearapharyngeal and retropharyngeal spaces (Fig 3). Theediastinal space also was involved, and no evidence of any

uid collection or mass formation was seen. From thesendings, a diagnosis of cervicofacial subcutaneous emphy-ema and pneumomediastinum was made.

The patient was admitted for airway monitoring and re-eived prophylactic intravenous antibiotic therapy with flo-

IGURE 2. Dental x-ray. The right upper first premolar with aorcelain fused metal crown showed a periapical radiolucent le-ion (arrow).

mai et al. Laser-Induced Emphysema. J Oral Maxillofac Surg 2009.

IGURE 3. Plain axial computed tomography (CT) scan. CT showsarapharyngeal, and retropharyngeal spaces (B), and the deep n

mai et al. Laser-Induced Emphysema. J Oral Maxillofac Surg 2009.

oxef sodium (Shionogi and Co, Osaka, Japan). On the fol-owing day, the cervicofacial swelling was slightly reduced andhe swollen eye was opened, followed 3 days later by a markedmprovement in trismus and dysphagia. The patient was dis-harged 6 days after the laser surgery with complete resolutionf the swelling and without complications (Fig 4).

iscussion

Laser therapy has developed rapidly and is nowsed commonly by general dental practitioners and

IGURE 4. Clinical appearance on discharge. The cervicofacialmphysema has resolved.

mai et al. Laser-Induced Emphysema. J Oral Maxillofac Surg 2009.

ve emphysema from the temporal area (A), the pterygomandibular,a (C) to the mediastinal space (D) (arrow).

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430 LASER-INDUCED EMPHYSEMA

ral surgeons.11,12 It has received Food and Drugdministration (FDA) approval for a number of dentalnd surgical soft-tissue procedures, including hemato-tatic assistance, tumor removal, gingivoectomy, aph-hous ulcer treatment, removal of canal filling mate-ial, gingival sulcular debridement, and abscessncision and drainage.11 However, laser interventionas been associated with various complications. Oneatient died recently when over-pressurization with a

et of inert gas during laparoscopic coagulation of theiver caused venous gas embolism.14 With regard toubcutaneous emphysema, although this is usually aelf-limiting condition with rapid recovery,1 it canead to potentially life-threatening complications re-uiring emergency intervention.2 In 1 series, severemphysematous complications arose during transoralO2 laser surgery for carcinoma of the larynx andypopharynx in 3 of 275 patients.15

Although a case of cervicofacial emphysema byaser therapy has been reported,13 to our knowledgehe present case is the first English-language report ofider spread cervicofacial emphysema and pneumo-ediastinum by intraoral laser irradiation. A high-

ntensity neodymium gas and yttrium synthetic crys-al, aluminum, and perovskite (Nd:YAP) laser haseen used as palliative therapy to decrease bacterialora in the periapical lesion through the fistula chan-el.16 In the present case, the tip of the laser hand-iece might have been in close proximity to thebscess cavity during irradiation. In this situation, thessist air would have been directly introduced underhe periosteum through the abscess cavity.

Several reports have described the access route ofas or air dissection in subcutaneous emphysema af-er dental procedures.1,2,6,7 We consider the route inhe present case as follows. The infiltration anesthe-ia, if the solution was injected under the periosteum,ikely lead to surrounding periosteal exfoliation, andlso desensitized against the local pain and discomfortccurring as an initial symptom of the air dissection inmphysema. Air from the laser tip entered the con-ective tissue surrounding the apex of the upperremolar and accessed the canine fossa and buccalpace, resulting in swelling of the periorbital area andheek. The subcutaneous air track extended superi-rly to the temporal space and inferiorly to the ptery-omandibular and parapharyngeal spaces, provokinghe trismus and dysphagia. It then traveled posteriorlynd entered the opposite parapharyngeal spacehrough the retropharyngeal space. The air alsoracked along the carotid sheath and descended to theediastinum, causing the discomfort in the chest.Patients with severe subcutaneous emphysema and

neumomediastinum should be admitted and closelybserved. In the present case, it was suspected that

he evaporated tissue debris and large amount of

acteria derived from the abscess were widely intro-uced into the soft tissue planes, followed by deepeck infection and mediastinitis.17 Although no ran-omized case controlled study on the use of antibiot-

cs for cervicofacial emphysema has been reported,arlier studies recommend chemoprophylaxis.1,4,7,8

e therefore included intravenous antibiotic use inhis patient to prevent related complications.

Prevention of laser-induced emphysema in access-ng a closed or narrow cavity such as a submucosalbscess or surgical defect requires careful adjustmentf the assist air flow and the avoidance of focused androlonged laser irradiation. The use of the com-ressed air system of a laser device is not alwaysecessary, but compressed air is essential in the op-ration of a high-speed handpiece. The present caseoes not call into question the usefulness of laserherapy; rather, it illustrates that the risk of criticalomplications increases with inadvertent manipula-ion of compressed air-equipped lasers.

eferences1. Heyman SN, Babayof I: Emphysematous complications in den-

tistry, 1960-1993: An illustrative case and review of the litera-ture. Quintessence Int 26:535, 1995

2. Sekine J, Irie A, Dotsu H, et al: Bilateral pneumothorax withextensive subcutaneous emphysema manifested during third mo-lar surgery. A case report. Int J Oral Maxillofac Surg 29:355, 2000

3. Sood T, Pullinger R: Pneumomediastinum secondary to dentalextraction. Emerg Med J 18:517, 2001

4. Torgay A, Aydin E, Cilasun U, et al: Subcutaneous emphysemaafter dental treatment: A case report. Paediatr Anaesth 16:314, 2006

5. Shackelford D, Casani JA: Diffuse subcutaneous emphysema,pneumomediastinum, and pneumothorax after dental extrac-tion. Ann Emerg Med 22:248, 1993

6. Capes JO, Salon JM, Wells DL: Bilateral cervicofacial, axillary,and anterior mediastinal emphysema: A rare complication ofthird molar extraction. J Oral Maxillofac Surg 57:996, 1999

7. Mather AJ, Stoykewych AA, Curran JB: Cervicofacial and medi-astinal emphysema complicating a dental procedure. J CanDent Assoc 72:565, 2006

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9. Hulsmann M, Hahn W: Complications during root canal irriga-tion—Literature review and case reports. Int Endod J 33:186, 2000

0. Eleazer PD, Eleazer KR: Air pressures developed beyond theapex from drying root canals with pressurized air. J Endod24:833, 1998

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