Spontaneous surgical emphysema of the larynx following hyperextension of the neck

Jeremy Batt; Natalia White; Simon Dennis

doi:10.1093/jscr/rju003

Batt, Jeremy; White, Natalia; Dennis, Simon

2014-03-04 00:00:00

JSCR 2014; 3 (2 pages) doi:10.1093/jscr/rju003 Case Report Spontaneous surgical emphysema of the larynx following hyperextension of the neck Jeremy Batt , Natalia White and Simon Dennis Department of ENT, Salisbury District Hospital, Salisbury, UK *Correspondence address. Department of ENT, Salisbury District Hospital, Salisbury, SP2 8QR, UK. Tel: 01722 336262; E-mail: jeremy.batt@doctors.org.uk Received 12 November 2013; revised 4 January 2014; accepted 12 January 2014 Surgical emphysema of the larynx is rare in the absence of trauma and there are a paucity of case reports that describe such conditions. We present what we believe to be an unusual, atrau- matic mechanism for mucosal breech of the larynx with subsequent surgical emphysema. Nasendoscopy revealed oedema of the arytenoid cartilage and computed tomography revealed moderate subcutaneous emphysema of the larynx. No fracture was seen. After conservative management the patient made a complete recovery. INTRODUCTION dynamic and real-time evaluation of the vocal cords and revealed signiﬁcant bruising and swelling of the right aryten- Surgical emphysema in the larynx has been well documented oid cartilage. Potential cord avulsion or paralysis was not in the scenario of both penetrating injury and blunt trauma [1]. identiﬁed. A computed tomography (CT) scan was subse- However, there seems to be a paucity of reports of other, more quently arranged to further assess the laryngeal anatomy and unusual causes. Here we present a case of thyroid cartilage was reported to show locules of free air in the soft tissues of crepitus in the presence of laryngeal surgical emphysema the neck with generalized oedema of the paraglottic tissues caused by isolated and unforced hyperextension of the neck. (Fig. 1). There was no fracture of the cartilage. The patient was admitted for strict airway observation, given a stat dose of IV steroid and started on IV antibiotic to cover supraglotittis. CASE REPORT Blood biochemistry and haematology samples were normal, with the exception of the C-reactive protein (a marker of in- A 39-year-old male patient with a background of type II dia- ﬂammation), which was 58 mg/l. Repeat nasendoscopic exam- betes, spina biﬁda and meningocele hydrocephalus presented ination the following day showed that the bruising had to the emergency ENT clinic with a 2-day history of a throat migrated into the right vocal fold and a new fullness in the left complaint. He described that while hyperextending his neck pyriform fossa. By Day 3 following admission the nasendo- to ﬁnish his cup of coffee he felt a sudden crack in the middle scopic examination was improving to normal and the right aryt- and central portion of his throat. This crack produced a sound enoid cartilage was seen to be less ﬂoppy. By this time the that was also heard by his partner on the other side of the patient’s pain was settling, although the hoarseness of voice room. The patient subsequently experienced a spontaneous was still present. He was discharged with 7 days of oral antibio- coughing ﬁt. During the history, he described pain over the tics and was reviewed in ENT clinic at 1 week where, although thyroid cartilage, odynophagia, pain on moving his neck and a his voice was still hoarse, the nasendoscopic examination was hoarse voice. He also described the sensation of having some- normal. By 6 weeks, the voice had settled, the thyroid cartilage thing ﬂapping in his throat while breathing. He denied any crepitus was gone and the larynx had returned to normal. recent history of throat trauma and had no other ENT com- plaints. On examination he had a tender thyroid cartilage with palpable crepitus of the thyroid cartilage when balloting it DISCUSSION between the ﬁngers of each hand. There was no palpable sur- gical crepitus of the soft tissues of the neck and no lymph- Laryngeal surgical emphysema is a condition that is related adenopathy. Flexible ﬁbre optic nasendoscopy allowed almost exclusively to laryngeal trauma. The mechanism for Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http ://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Page 2 of 2 J. Batt et al. increasing laryngeal pressure, forced air through the acute mucosal defect and into the soft tissues of the neck, the result of which being the surgical crepitus as identiﬁed on the CT scan. Only a handful of cases have ever been reported theorizing coughing as a cause of acute and dramatic laryngeal rupture, one of which being an elderly patient with weakened laryn- geal structure secondary to chronic corticosteroid use [3, 4]. Patients with minor laryngeal lacerations in the absence of detectable laryngeal fracture can be treated with humidiﬁed oxygen which may reduce crust formation and help to minim- ize transient cilliary dysfunction. Patients should be admitted for airway observation and for intravenous stat dose steroid to minimize potential laryngeal oedema and hence airway and Figure 1: CT scan showing subcutaneous emphysema of the larynx. airﬂow limitation. Keeping voice exertion to a minimum is considered to minimize oedema, haematoma and subcutane- such injury is usually secondary to blunt trauma of the larynx ous emphysema. Restricting oral input to clear ﬂuids may in combination with forced hyperextension of the neck, which protect the area from potential further injury. While antibiotics leaves the larynx exposed and vulnerable to injury. What are may not be mandatory in such conditions, systemic IV anti- less well documented are cases of laryngeal surgical emphyse- microbial may deliver an additional degree of protection ma in the absence of such trauma. One case series of 236 against the airﬂow limitation and resulting airway compromise patients admitted with upper airodigestive tract injury reported one may see with inﬂammation and oedema expected in local no cases of laryngeal injury resulting in surgical crepitus in spread of possible infection through a mucosal breach. the absence of trauma [1]. The classical symptoms of anterior In conclusion, while laryngeal injury resulting in surgical neck pain, difﬁculty with breathing and swallowing and emphysema almost exclusively occurs in the context of hoarseness or a change in voice may be present to varying trauma more subtle mechanisms may result in similar injuries. degrees with any given presentation of laryngeal pathology. Based on our experience it is the recommendation of this Change in phonation can be a reasonable sign of vocal cord paper for others to consider the potential for signiﬁcant laryn- disturbance with only 17% of patients who had cord immobil- geal crepitus when presented with seemingly benign laryngeal ity displaying excellent voice quality [2]. The physical ﬁnd- injury and investigate appropriately with CT imaging. ings of stridor, subcutaneous emphysema, laryngeal tenderness and loss of thyroid cartilage structure may also be REFERENCES present. While the patient reported a distinct lack of obvious exter- 1. Goudy SL, Miller FB, Bumpous JM. Neck crepitance: evaluation and nal trauma or disturbance of the anatomy of the larynx and la- management of suspected upper aerodigestive tract injury. Laryngoscope 2002;112:791–5. ryngeal mucosa it may have been possible that a small 2. Leopold DA. Laryngeal trauma. A historical comparison of treatment mucosal tear may have been caused during the swallowing methods. Arch Otolaryngol 1983;109:106–12. action in combination with neck hyperextension, an action 3. Rousie C, Van Damme H, Radermecker MA, Reginster P, Tecqmenne C, Limet R. Spontaneous tracheal rupture: a case report. Acta Chir Belg that may increase tension in the soft tissues of the larynx. 2004;104:204–8. With such damage having been sustained it may have indeed 4. Roh JL, Lee JH. Spontaneous tracheal rupture after sever coughing in a 7 been possible that the subsequent coughing ﬁt, through year old boy. Pediatrics 2006;118:224–7.

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Journal of Surgical Case Reports Oxford University Press

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Spontaneous surgical emphysema of the larynx following hyperextension of the neck

$JSCR 2014; 3 (2 pages) doi:10.1093/jscr/rju003 Case Report Spontaneous surgical emphysema of the larynx following hyperextension of the neck Jeremy Batt , Natalia White and Simon Dennis Department of ENT, Salisbury District Hospital, Salisbury, UK *Correspondence address. Department of ENT, Salisbury District Hospital, Salisbury, SP2 8QR, UK. Tel: 01722 336262; E-mail: jeremy.batt@doctors.org.uk Received 12 November 2013; revised 4 January 2014; accepted 12 January 2014 Surgical emphysema of the larynx is rare in the absence of trauma and there are a paucity of case reports that describe such conditions. We present what we believe to be an unusual, atrau- matic mechanism for mucosal breech of the larynx with subsequent surgical emphysema. Nasendoscopy revealed oedema of the arytenoid cartilage and computed tomography revealed moderate subcutaneous emphysema of the larynx. No fracture was seen. After conservative management the patient made a complete recovery. INTRODUCTION dynamic and real-time evaluation of the vocal cords and revealed signiﬁcant bruising and swelling of the right aryten- Surgical emphysema in the larynx has been well documented oid cartilage. Potential cord avulsion or paralysis was not in the scenario of both penetrating injury and blunt trauma [1]. identiﬁed. A computed tomography (CT) scan was subse- However, there seems to be a paucity of reports of other, more quently arranged to further assess the laryngeal anatomy and unusual causes. Here we present a case of thyroid cartilage was reported to show locules of free air in the soft tissues of crepitus in the presence of laryngeal surgical emphysema the neck with generalized oedema of the paraglottic tissues caused by isolated and unforced hyperextension of the neck. (Fig. 1). There was no fracture of the cartilage. The patient was admitted for strict airway observation, given a stat dose of IV steroid and started on IV antibiotic to cover supraglotittis. CASE REPORT Blood biochemistry and haematology samples were normal, with the exception of the C-reactive protein (a marker of in- A 39-year-old male patient with a background of type II dia- ﬂammation), which was 58 mg/l. Repeat nasendoscopic exam- betes, spina biﬁda and meningocele hydrocephalus presented ination the following day showed that the bruising had to the emergency ENT clinic with a 2-day history of a throat migrated into the right vocal fold and a new fullness in the left complaint. He described that while hyperextending his neck pyriform fossa. By Day 3 following admission the nasendo- to ﬁnish his cup of coffee he felt a sudden crack in the middle scopic examination was improving to normal and the right aryt- and central portion of his throat. This crack produced a sound enoid cartilage was seen to be less ﬂoppy. By this time the that was also heard by his partner on the other side of the patient’s pain was settling, although the hoarseness of voice room. The patient subsequently experienced a spontaneous was still present. He was discharged with 7 days of oral antibio- coughing ﬁt. During the history, he described pain over the tics and was reviewed in ENT clinic at 1 week where, although thyroid cartilage, odynophagia, pain on moving his neck and a his voice was still hoarse, the nasendoscopic examination was hoarse voice. He also described the sensation of having some- normal. By 6 weeks, the voice had settled, the thyroid cartilage thing ﬂapping in his throat while breathing. He denied any crepitus was gone and the larynx had returned to normal. recent history of throat trauma and had no other ENT com- plaints. On examination he had a tender thyroid cartilage with palpable crepitus of the thyroid cartilage when balloting it DISCUSSION between the ﬁngers of each hand. There was no palpable sur- gical crepitus of the soft tissues of the neck and no lymph- Laryngeal surgical emphysema is a condition that is related adenopathy. Flexible ﬁbre optic nasendoscopy allowed almost exclusively to laryngeal trauma. The mechanism for Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http ://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Page 2 of 2 J. Batt et al. increasing laryngeal pressure, forced air through the acute mucosal defect and into the soft tissues of the neck, the result of which being the surgical crepitus as identiﬁed on the CT scan. Only a handful of cases have ever been reported theorizing coughing as a cause of acute and dramatic laryngeal rupture, one of which being an elderly patient with weakened laryn- geal structure secondary to chronic corticosteroid use [3, 4]. Patients with minor laryngeal lacerations in the absence of detectable laryngeal fracture can be treated with humidiﬁed oxygen which may reduce crust formation and help to minim- ize transient cilliary dysfunction. Patients should be admitted for airway observation and for intravenous stat dose steroid to minimize potential laryngeal oedema and hence airway and Figure 1: CT scan showing subcutaneous emphysema of the larynx. airﬂow limitation. Keeping voice exertion to a minimum is considered to minimize oedema, haematoma and subcutane- such injury is usually secondary to blunt trauma of the larynx ous emphysema. Restricting oral input to clear ﬂuids may in combination with forced hyperextension of the neck, which protect the area from potential further injury. While antibiotics leaves the larynx exposed and vulnerable to injury. What are may not be mandatory in such conditions, systemic IV anti- less well documented are cases of laryngeal surgical emphyse- microbial may deliver an additional degree of protection ma in the absence of such trauma. One case series of 236 against the airﬂow limitation and resulting airway compromise patients admitted with upper airodigestive tract injury reported one may see with inﬂammation and oedema expected in local no cases of laryngeal injury resulting in surgical crepitus in spread of possible infection through a mucosal breach. the absence of trauma [1]. The classical symptoms of anterior In conclusion, while laryngeal injury resulting in surgical neck pain, difﬁculty with breathing and swallowing and emphysema almost exclusively occurs in the context of hoarseness or a change in voice may be present to varying trauma more subtle mechanisms may result in similar injuries. degrees with any given presentation of laryngeal pathology. Based on our experience it is the recommendation of this Change in phonation can be a reasonable sign of vocal cord paper for others to consider the potential for signiﬁcant laryn- disturbance with only 17% of patients who had cord immobil- geal crepitus when presented with seemingly benign laryngeal ity displaying excellent voice quality [2]. The physical ﬁnd- injury and investigate appropriately with CT imaging. ings of stridor, subcutaneous emphysema, laryngeal tenderness and loss of thyroid cartilage structure may also be REFERENCES present. While the patient reported a distinct lack of obvious exter- 1. Goudy SL, Miller FB, Bumpous JM. Neck crepitance: evaluation and nal trauma or disturbance of the anatomy of the larynx and la- management of suspected upper aerodigestive tract injury. Laryngoscope 2002;112:791–5. ryngeal mucosa it may have been possible that a small 2. Leopold DA. Laryngeal trauma. A historical comparison of treatment mucosal tear may have been caused during the swallowing methods. Arch Otolaryngol 1983;109:106–12. action in combination with neck hyperextension, an action 3. Rousie C, Van Damme H, Radermecker MA, Reginster P, Tecqmenne C, Limet R. Spontaneous tracheal rupture: a case report. Acta Chir Belg that may increase tension in the soft tissues of the larynx. 2004;104:204–8. With such damage having been sustained it may have indeed 4. Roh JL, Lee JH. Spontaneous tracheal rupture after sever coughing in a 7 been possible that the subsequent coughing ﬁt, through year old boy. Pediatrics 2006;118:224–7.$

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Spontaneous surgical emphysema of the larynx following hyperextension of the neck

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Spontaneous surgical emphysema of the larynx following hyperextension of the neck

Spontaneous surgical emphysema of the larynx following hyperextension of the neck

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