Foreign body - What is unusual
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《美国医学杂志》
Department of Pediatrics, Karnataka Institute of Medical Sciences, Hubli-580021, Karnataka, India
Subcutaneous emphysema of neck occurs usually due to tracheostomy, dental extraction, injury to neck, asthma, respiratory infection and rarely occurs due to sharp foreign bodies in food or in air passage.[1],[2],[3],[4] Herein, we are reporting a case of subcutaneous emphysema of neck and chest secondary to foreign body (areca nut) in bronchus.
A 5-year-old male child was admitted in our pediatric ward with cough and fever and swelling in neck and upper half of chest of 3 days duration.There was no trauma to chest/neck. No history of foreign body ingestion or choking or wheezing or stridor. Child was completely immunized as per IAP schedule. Child had tachypnea and tachycardia at presentation. Throat examination revealed congested pharynx. Swelling was clinking, crepitant and crunching on palpation and tender to touch. Respiratory system revealed tracheal shift to left side, and dull note and decreased air entry on left hemi thorax and hyper resonant note on right hemi thorax. Other systemic examination was normal. Chest X-ray showed hyper inflation on right side with air shadows in neck, axilla and mediastinum. High Resolution Computed Tomography (HRCT ) of chest showed abrupt cut off of the left lower lobe bronchus- Foreign body with left lower lobe collapse with left upper lobe hyperinflation with emphysema involving the mediastinum, chest wall and neck Figure1. Bronchoscopy showed foreign body (areca nut) in left main bronchus with thick yellowish pus. Subcutaneous emphysema was reduced within 3 days of removal of foreign body.
Subcutaneous emphysema occurs secondary to foreign body because of peculiar arrangement of fascial planes in the neck, chest and abdomen, and an excessive pressure gradient at the alveolar level, facilitates extra alveolar migration of air in the subcutaneous tissue.[5],[6] In our case, the foreign body which was present in the left main bronchus, works as a valve permitting air to enter but not to leave again. Increasing air pressure in the pulmonary alveoli caused their rupture, and escaping air along the large pulmonary vessels to the mediastinum. From there, the emphysema extended to the chest, neck and head through the subcutaneous tissue. A high index of suspicion for tracheobronchial foreign body is required in atypical presentation of subcutaneous emphysema.
References
1. Aytac A, Yurdakul Y, Ikizler C, Olga R & Saylam A. Inhalation of foreign bodies in children-report of 500 cases. J Thoracic and Cardiovascular Surgery 1977; 74 : 145-151.
2. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children- A review of 225 cases. Ann Otol Rhinol Laryngol 1980; 89 : 434-436.
3. Jhamb U, Sethi GR, Puri R. Kapoor S. Surgical emphysema: a rare presentation of foreign body inhalation. Pediatr Emerg Care 2004; 20(5) : 311-313.
4. Kullaa-Mikkonen A, Mikkonen M. Subcutaneous emphysema. Oral Surg 1982; 20(3); 200-202.
5. Saoji R, Ramachandra C, D'cluz AJ. Subscutaneous emphysema: an unsual presentation of foreign body in the airway. Pediatr Surg 1955; 30(6) : 860-862.
6. Daniilidis J, Petropouloulos P, Iliadis T. Mediastinal emphysema extending to the chest, neck and head as complication of a foreign body in bronchi. Monatsschr Kinderheiikd 1981; 129(9) : 541-543.(Ratageri Vinod H, Shepur )
Subcutaneous emphysema of neck occurs usually due to tracheostomy, dental extraction, injury to neck, asthma, respiratory infection and rarely occurs due to sharp foreign bodies in food or in air passage.[1],[2],[3],[4] Herein, we are reporting a case of subcutaneous emphysema of neck and chest secondary to foreign body (areca nut) in bronchus.
A 5-year-old male child was admitted in our pediatric ward with cough and fever and swelling in neck and upper half of chest of 3 days duration.There was no trauma to chest/neck. No history of foreign body ingestion or choking or wheezing or stridor. Child was completely immunized as per IAP schedule. Child had tachypnea and tachycardia at presentation. Throat examination revealed congested pharynx. Swelling was clinking, crepitant and crunching on palpation and tender to touch. Respiratory system revealed tracheal shift to left side, and dull note and decreased air entry on left hemi thorax and hyper resonant note on right hemi thorax. Other systemic examination was normal. Chest X-ray showed hyper inflation on right side with air shadows in neck, axilla and mediastinum. High Resolution Computed Tomography (HRCT ) of chest showed abrupt cut off of the left lower lobe bronchus- Foreign body with left lower lobe collapse with left upper lobe hyperinflation with emphysema involving the mediastinum, chest wall and neck Figure1. Bronchoscopy showed foreign body (areca nut) in left main bronchus with thick yellowish pus. Subcutaneous emphysema was reduced within 3 days of removal of foreign body.
Subcutaneous emphysema occurs secondary to foreign body because of peculiar arrangement of fascial planes in the neck, chest and abdomen, and an excessive pressure gradient at the alveolar level, facilitates extra alveolar migration of air in the subcutaneous tissue.[5],[6] In our case, the foreign body which was present in the left main bronchus, works as a valve permitting air to enter but not to leave again. Increasing air pressure in the pulmonary alveoli caused their rupture, and escaping air along the large pulmonary vessels to the mediastinum. From there, the emphysema extended to the chest, neck and head through the subcutaneous tissue. A high index of suspicion for tracheobronchial foreign body is required in atypical presentation of subcutaneous emphysema.
References
1. Aytac A, Yurdakul Y, Ikizler C, Olga R & Saylam A. Inhalation of foreign bodies in children-report of 500 cases. J Thoracic and Cardiovascular Surgery 1977; 74 : 145-151.
2. Rothmann BF, Boeckman CR. Foreign bodies in the larynx and tracheobronchial tree in children- A review of 225 cases. Ann Otol Rhinol Laryngol 1980; 89 : 434-436.
3. Jhamb U, Sethi GR, Puri R. Kapoor S. Surgical emphysema: a rare presentation of foreign body inhalation. Pediatr Emerg Care 2004; 20(5) : 311-313.
4. Kullaa-Mikkonen A, Mikkonen M. Subcutaneous emphysema. Oral Surg 1982; 20(3); 200-202.
5. Saoji R, Ramachandra C, D'cluz AJ. Subscutaneous emphysema: an unsual presentation of foreign body in the airway. Pediatr Surg 1955; 30(6) : 860-862.
6. Daniilidis J, Petropouloulos P, Iliadis T. Mediastinal emphysema extending to the chest, neck and head as complication of a foreign body in bronchi. Monatsschr Kinderheiikd 1981; 129(9) : 541-543.(Ratageri Vinod H, Shepur )