Emphysema is characterised by loss of elasticity of the lung tissue; destruction of structures supporting the alveoli; and destruction of capillaries feeding the alveoli. The result is that the small airways collapse during expiration, leading to an obstructive form of lung disease (air is trapped in the lungs in obstructive lung diseases). Features are: shortness of breath on exertion--particularly when climbing stairs or inclines (and later at rest), hyperventilation and an expanded chest. As emphysema progresses, clubbing of the fingers may be observed, a feature of longstanding hypoxia.

Emphysema patients are sometimes referred to as "pink puffers". This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why emphysema patients do not appear cyanotic as chronic bronchitis (another COPD disorder) sufferers often do; hence they are "pink" puffers (adequate oxygen levels in the blood) and not "blue" bloaters (cyanosis; inadequate oxygen in the blood).

Diagnosis

Diagnosis is by spirometry (lung function testing), including diffusion testing. Other investigations might include X-rays, high resolution spiral chest CT-scan, bronchoscopy (when other lung disease is suspected, including malignancy), blood tests, pulse oximetry and arterial blood gas sampling.

Pathophysiology

The scientific definition of emphysema is:

"Permanent destructive enlargement of the airspaces distal to the terminal bronchioles without obvious fibrosis".

Hence, the definite diagnosis is made by a pathologist. However, we can easily ascertain clinical diagnosis by history, clinical examination, chest radiography and lung function tests.

In normal breathing, air is drawn in through the bronchial passages and down into the increasingly fine network of tubing in the lungs called the alveoli, which are many thousands of tiny sacs surrounded by capillaries. These absorb the oxygen and transfer it into the blood. When toxins such as smoke are breathed into the lungs, the particles are trapped by the hairs and cannot be exhaled, leading to a localised inflammatory response. Chemicals released during the inflammatory response (trypsin, elastase, etc.) are released and begin breaking down the walls of alveoli. This leads to fewer but larger alveoli, with a decreased surface area and a decreased ability to take up oxygen and lose carbon dioxide. The activity of another molecule called alpha 1-antitrypsin normally neutralizes the destructive action of one of these damaging molecules.

After a prolonged period, hyperventilation becomes inadequate to maintain high enough oxygen levels in the blood, and the body compensates by vasoconstricting appropriate vessels. This leads to pulmonary hypertension. This leads to enlargement and increased strain on the right side of the heart, which in turn leads to peripheral edema (swelling of the peripherals) as blood gets backed up in the systemic circulation, causing fluid to leave the circulatory system and accumulate in the tissues.

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Surgical emphysema in the neck as a result of a dental procedure
From Ear, Nose & Throat Journal, 11/1/05 by Moghira Iqbal

Abstract

We report the development of subcutaneous emphysema in a middle-aged woman that occurred several hours after she had undergone a dental restoration procedure. The patient presented to the emergency department, and she was admitted for observation and prophylactic antibiotic coverage. She recovered in 3 days without further intervention and was discharged.

Introduction

Subcutaneous emphysema, pneumomediastinum, and pneumothorax can occur as a result of many procedures, including tracheotomy, direct laryngoscopy, and esophagoscopy. (1) These accumulations of air are rare after a dental procedure. We report the case of a woman who developed subcutaneous emphysema after she had undergone a dental restoration procedure.

Case report

A 50-year-old woman presented to the emergency department in the middle of the night with severe odynophagia. She had undergone restoration of a fractured mandibular molar several hours earlier. On initial examination, her pulse rate was 110 bpm, her blood pressure was 150/80 mm Hg, and her temperature was 36.5[degrees] C (98[degrees] F). She was unable to swallow her saliva because of excruciating pain. She was in no respiratory distress, and she maintained an oxygen saturation level of 98% on room air. Mild swelling was noted on the left side of her upper neck and crepitus in the left temporal, malar, submandibular, and submental areas. Findings on examination of the oral cavity were normal except for signs of local trauma at the site of the dental procedure.

Flexible endoscopy revealed that the airway was normal up to the carina tracheae. Findings on the remainder of the clinical examination were unremarkable. X-rays of the neck revealed the presence of air in soft-tissue spaces and in the prevertebral area (figure).

[ILLUSTRATION OMITTED]

The patient was admitted and kept under observation with prophylactic antibiotic coverage. The emphysema and dysphagia resolved after 3 days, and the patient was discharged home in stable condition.

Discussion

When surgical emphysema occurs in the head and neck, it is usually secondary to trauma or a rupture of the pulmonary bullae. Subcutaneous emphysema following a dental procedure was first reported in 1900 by Turnbull, who described emphysema of the face following a premolar extraction. (2) In 1957, Shovelton classified subcutaneous emphysema into four categories according to its cause (3):

* a patient-incited reaction, such as self-inflicted trauma

* the direct injection of air

* the result of a prolonged surgical procedure

* no identifiable cause

More recent reports have implicated the turbine drill as a cause of direct injection of air into the fascial planes. Torres-Melero et al reported a case of pneumomediastinum resulting from dental work with a high-speed air turbine drill. (4) Shackelford and Casani (5) and Chen et al (6) have advised dentists to take special precautions when using a turbine drill.

Ali et al discussed emphysema resulting from the use of rotor drills in dental procedures. (7) Jovanovic-Bateman and Hedreville described sudden emphysema following dental drilling that resulted in severe pain and dyspnea. (8)

The roots of the first, second, and third molars communicate directly with the sublingual and submandibular spaces. The sublingual space is also in direct communication with the pterygomandibular, parapharyngeal, and retropharyngeal spaces. The turbine drill and other instruments are equipped with pressurized air- and water-flow systems. After a tooth has been extracted, the roots may give way to injected air and result in surgical emphysema.

Our patient had undergone root canal treatment on the same tooth 12 years earlier. During the dental restoration that precipitated her emphysema, the dentist had used an air-and-water syringe that operates at low air pressure. The emphysema occurred even though the tooth was not extracted. Obviously, this case indicates that dental extraction is not the only circumstance in which a dental procedure can lead to surgical emphysema; even minor procedures that involve the use of air-flow systems can result in this condition. A case of surgical emphysema following dental restoration work was also reported by Bavinger. (9)

Otolaryngologists and maxillofacial and dental surgeons should be aware of the fact that any dental procedure involving the use of air turbines can potentially result in surgical emphysema.

Moghira Iqbal, MBBS; Mubasher Ikram, FCPS; Farhan Raza, BDS, MCPS; Ninette Banday, BDS, MPH, DMSC

Reprint requests: Dr. Mubasher Ikram, Department of Otolaryngology-Head and Neck Surgery, Aga Khan University Hospital, Stadium Rd., Box 3500, Karachi 74800, Pakistan. Phone: 92-21-4859-4770; fax: 92-21-493-4294 or 493-2095; e-mail: mubasher. ikram@aku.edu

References

(1.) Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.

(2.) Turnbull A. A remarkable coincidence in dental surgery. Br Med J 1900:1:131.

(3.) Shovelton DS. Surgical emphysema as a complication of dental operations. Br Dent J 1957;102:125-9.

(4.) Torres-Melero J, Arias-Diaz J, Balibrea JL. Pneumomediastinum secondary to use of a high speed air turbine drill during a dental extraction. Thorax 1996;51:339-40.

(5.) Shackelford D, Casani JA. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction. Ann Emerg Med 1993;22:248-50.

(6.) Chen SC, Lin FY, Chang KJ. Subcutaneous emphysema and pneumomediastinum after dental extraction. Am J Emerg Med 1999;17:678-80.

(7.) Ali A, Cunliffe DR, Watt-Smith SR. Surgical emphysema and pneumomediastinum complicating dental extraction. Br Dent J 2000;188:589-90.

(8.) Jovanovic-Bateman L, Hedreville R. [Subcutaneous emphysema and pneumomediastinum after dental drilling]. Rev Laryngol Otol Rhinol (Bord) 2003; 124:199-200.

(9.) Bavinger JV. Subcutaneous and retropharyngeal emphysema following dental restoration: An uncommon complication. Ann Emerg Med 1982;11:371-4.

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Iqbal and Dr. Ikram) and the Department of Dentistry (Dr. Raza and Dr. Banday), Aga Khan University Hospital, Karachi, Pakistan.

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