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 Table of Contents  
Year : 2016  |  Volume : 28  |  Issue : 2  |  Page : 203-205

Spontaneous retropharyngeal emphysema postendodontic treatment

1 Department of Conservative Dentistry and Endodontics, Maratha Mandal Dental College, Belgaum, Karnataka, India
2 Department of Prosthodontics, Maratha Mandal Dental College, Belgaum, Karnataka, India
3 Department of Conservative Dentistry and Endodontics, Rural Dental College, Loni, Maharashtra, India
4 Department of Oral Diagnosis, Rural Dental College, Loni, Maharashtra, India

Date of Web Publication9-Dec-2016

Correspondence Address:
Praveen Shrishail Byakod
Department of Conservative Dentistry and Endodontics, Maratha Mandal Dental College, Bauxite Road, Belgaum - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-7212.195441

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Facial and cervical emphysema occurs as a result of air entering through the facial planes, a condition rarely seen in dental practice. In dentistry, compressed air is used to run the high-speed airotor drills and three-way air syringes. These two equipment are to be used with great precaution, especially when minor surgical procedures are done. It is highly recommended not to use these in major surgical procedures. Here, we present a case of spontaneous retropharyngeal emphysema, iatrogenically induced in a 64-year-old healthy patient undergoing root canal therapy on mandibular canines 33 and 43. Diagnosis has to be precise as this condition mimics allergic reactions and hematoma.

Keywords: Airotor drill; dental surgery; pneumomediastinum; subcutaneous emphysema.

How to cite this article:
Byakod PS, Byakod PP, Biradar B, Biradar S. Spontaneous retropharyngeal emphysema postendodontic treatment. Endodontology 2016;28:203-5

How to cite this URL:
Byakod PS, Byakod PP, Biradar B, Biradar S. Spontaneous retropharyngeal emphysema postendodontic treatment. Endodontology [serial online] 2016 [cited 2021 May 7];28:203-5. Available from: https://www.endodontologyonweb.org/text.asp?2016/28/2/203/195441

  Introduction Top

Spontaneous cervical emphysema is a very uncommon occurrence in dentistry. Usually, such conditions are noted in dental procedures with use of high-speed airotor drill, inadvertent use of three-way air syringe during major surgical procedures, pathologic process of pulmonary disease, and because of trauma.[1] This condition at times may mimic hematoma and some allergic conditions.

It is a potentially life-threatening condition, but the majority of cases are self-limiting and benign.[2] Emphysematous condition is usually managed by strict observation of the vital signs of the patient, and prophylactic antibiotic therapy may be administered if required. Some complications such as pneumothorax and mediastinitis may be associated with this. Here, in this article, we present a case of spontaneous retropharyngeal emphysema occurring as a result of endodontic therapy.

  Case Report Top

A 64-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with pain in lower anterior teeth for 1 week, on clinical examination, it was noted that both 33 and 43 would have to undergo root canal therapy.

During the procedure, high-speed airotor handpiece (Sybron Endo T3 mini) was used for access opening, which was followed by biomechanical preparation with rotary instruments (ProTaper universal) and finally intracanal medication of calcium hydroxide iodoform paste (Meatpex; Meta Biomed Co. Ltd., Chungbuk, Korea) was placed. The patient was on the process of being discharged when the operator noticed swelling in the neck, cheek, and the infraorbital region on the right side of face [Figure 1].
Figure 1: Swelling in the neck, cheek, and the infraorbital region on the right side

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On examination, the swelling was noted in the submandibular region, the anterior part of the neck and the supraclavicular fossa. Although the patient had no specific complaints reported with mild discomfort while swallowing and difficulty on breathing. His trachea was not deviated, and there was no evidence of airway obstruction. Pulse, blood pressure, and heart sounds were normal. Subcutaneous crepitus was palpable over the neck, chest, and right cheek.

The patient was immediately shifted to the medical emergency ward for further medical examination and observation. All the vital signs were recorded and maintained for further comparison.

  • Blood pressure - 154/86 mmHg
  • Pulse rate - 98 beats/min
  • Respiratory rate - 26 beats/min
  • Body temperature - 36.8°C.

On physical examination, severe swelling of the cheek, neck, and infraorbital region was observed. This swelling was not associated with any tenderness and erythematous change. Laboratory findings did not reveal any abnormal readings.

  • WBC count - 5220/µl (neutrofills 44%)
  • Hemoglobin - 11.1 g/dl
  • Platelet count - 280,000/µl.

Other biomedical parameters were within normal range.

Radiograph (lateral neck) revealed the presence of subcutaneous emphysema in the submandibular region, neck, and upper chest [Figure 2].
Figure 2: Lateral neck roentgenography showing diffuse subcutaneous emphysema

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The patient was admitted for observation, and prophylactic antibiotics were administered (Augmentin Duo 625 BD), during 5 days patient recovered smoothly. The patient was discharged with complete resolution of the swelling and any associated symptoms [Figure 3].
Figure 3: Complete resolution of the swelling

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  Discussion Top

In this present case of spontaneous subcutaneous retropharyngeal emphysema, there was sudden onset of swelling in the infraorbital region, cheeks, and neck. Although the patient did not complain of any specific complaint, on examination crepitus was observed in the affected region, which is a classical sign of subcutaneous emphysema. Palpation of the swollen head and neck areas will elicit crepitus or a “Velcro” sensation that is not present in the other conditions. In most cases, this sign is detected immediately, but there are reports in which it may appear later, making diagnosis difficult.[3] Air can be introduced into the soft tissue spaces by several routes, but it usually passes through the dentoalveolar membrane or a root canal.[4]

Such spontaneous swelling postendodontic treatment leads us to suspect the use or misuse of irrigants (beyond the confines of the root canal) specially NaoCl (sodium hypochlorite), allergic reaction to any medications or intracanal dressing, and the inadvertent use of high-speed airotor drill or three-way air syringe. It should be noticed that surgery is not the only procedure at risk for the development of subcutaneous emphysema as cases have been described during restorative procedures, crown preparation, and endodontic therapy.[5]

The patient was without any specific symptoms but was curious to know the reason for the swelling. Later, he did complaint of mild breathing problem and difficulty in deglutition. The presence of free air on the retropharyngeal space may lead to  Eustachian tube More Details dysfunction and hearing loss, dysphonia, and dysphagia.[2]

On detailed review of the procedure followed, we had come to suspect the use of high-speed airotor drill and the three-way air syringe. The use of high-speed airotor drill is inevitable for any endodontic treatment, but the use of three-way air syringe, especially for drying the canal is questionable. The three-way air syringe has to be held perpendicular to the long axis of the teeth, and a gentle blast of air will aid in drying the contents of the pulp chamber. This procedure is commonly practiced in dentistry. In our opinion, it should be avoided as there is a greater risk of inducing air into the canal and pushing the contents of the canal beyond the confines of the root canal into the periapex. We would recommend using a pellet of cotton to accomplish the same, further drying of the root canal can be done with paper points.

Dental treatment with the use of compressed air with various equipment is known to cause subcutaneous emphysema; however, it is reported that subcutaneous emphysema and pneumomediastinum can also be seen after sneezing and nose blowing.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kim SW, Kang HH, Kang JY, Kim SK, Lee BY, Lee SH, et al. A case of pneumomediastinum and parapneumonic effusions following pharyngeal perforation caused by shouting. Yonsei Med J 2014;55:270-2.  Back to cited text no. 1
Döngel I, Bayram M, Uysal IO, Sunam GS. Subcutaneous emphysema and pneumomediastinum complicating a dental procedure. Ulus Travma Acil Cerrahi Derg 2012;18:361-3.  Back to cited text no. 2
Romeo U, Galanakis A, Lerario F, Daniele GM, Tenore G, Palaia G. Subcutaneous emphysema during third molar surgery: A case report. Braz Dent J 2011;22:83-6.  Back to cited text no. 3
Kim Y, Kim MR, Kim SJ. Iatrogenic pneumomediastinum with extensive subcutaneous emphysema after endodontic treatment: Report of 2 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e114-9.  Back to cited text no. 4
McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: A literature review. J Oral Maxillofac Surg 2009;67:1265-8.  Back to cited text no. 5
Damore DT, Dayan PS. Medical causes of pneumomediastinum in children. Clin Pediatr (Phila) 2001;40:87-91.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]


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