|Year : 2012 | Volume
| Issue : 1 | Page : 38-41
Subcutaneous emphysema: An unusual presentation of an unsuspected foreign body bronchus in an adult patient
Sushil K Aggarwal, Amit Keshri
Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
|Date of Web Publication||9-Apr-2012|
Sushil K Aggarwal
Department of Neurosurgery, SGPGIMS, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Foreign body in airway is common in children but extremely rare in adults. Here, we are presenting a case report of an adult patient with an unsuspected foreign body in the airway who presented unusually as widespread subcutaneous emphysema in neck. We did an extensive review of literature on this topic but could find only few cases with similar clinical presentation of asymptomatic inhaled foreign body in adults. This case underlines the fact that airway foreign bodies can have extremely unusual presentations and only a high degree of clinical suspicion can clinch the diagnosis. This case is being reported for its unusual presentation and its rarity.
Keywords: Betel nut, bronchus, epilepsy, foreign body, subcutaneous emphysema
|How to cite this article:|
Aggarwal SK, Keshri A. Subcutaneous emphysema: An unusual presentation of an unsuspected foreign body bronchus in an adult patient. J Laryngol Voice 2012;2:38-41
| Introduction|| |
Foreign body aspiration occurs mostly in children below 10 years of age due to incomplete laryngeal closure and inadequate swallowing reflex in this age.  Most commonly, vegetable matter such as seeds are accidentally inhaled into the airway in children. If foreign body lodges in the region of larynx, immediate stridor or choking results; impaction lower down in the bronchial lumen may be less dramatic or even asymptomatic.  Aspiration of foreign body is rare in adults, although it has been reported in some adults with central nervous system (C) dysfunction with suspicion of inhalation during an episode of seizures or in psychiatric illness. The common causes in adults are usually iatrogenic or traumatic. Here, we are presenting a rare case in which patient with an unsuspected foreign body in the lower airways presented to us with widespread subcutaneous emphysema in neck, dry cough, and moderate difficulty in breathing. The diagnosis and proper treatment got delayed in our case as patient could not recall any incidence of foreign body aspiration. The diagnosis for the cause of subcutaneous emphysema in our case was done through detailed history and examination along with necessary investigations. We are reporting this case for its rare presentation and to underline the fact that foreign bodies in airway pose both therapeutic as well as diagnostic challenge in routine clinical practice.
| Case Report|| |
A 20-year-old male patient presented to the outpatient department of our tertiary care hospital with chief complains of swelling in neck and upper chest, dry intractable cough, and difficulty in breathing for last 5 days. There was no history of neck or chest trauma or foreign body aspiration. On clinical examination, there were no signs and symptoms of upper airway obstruction, but mild tachycardia was present. Patient had diffuse swelling over neck, suprasternal region, and chest along with crepitus. Rest of the systemic examination was normal. On further elaboration of the history, the patient told that he was normal 20 days back when suddenly he had an episode of seizures. He was admitted at that time and was given anti-epileptic drugs and was subsequently discharged next day from the hospital. All investigations including X-ray chest, blood counts, and blood chemistry were normal during his stay at hospital. Patient after discharge developed dry cough which gradually worsened in due course of time in spite of taking medications. He again underwent all routine investigations along with X-ray chest which showed signs of mild pneumonitis in perihilar region of both main bronchi. Patient was put on antibiotics but he did not improve and slowly he started developing surgical emphysema of neck which got worsened gradually. Patient was immediately referred to our hospital for tertiary care management. Fresh X-ray chest revealed extensive subcutaneous emphysema [Figure 1]. On clinical examination and auscultation, we found that patient had decreased air entry in both the lungs along with crepitations. A suspicion of some foreign body aspiration was made and an emergency computed tomography (CT) scan of neck and thorax was done to look for any lung pathology. On CT scan, there was about 12 x 5-mm wide hyperdense linear foreign body present in both right and left main bronchi [Figure 2]. Patient also had mediastinal emphysema along with surgical emphysema of neck [Figure 3]. On reviewing the history, the patient recalled that he had a habit of chewing betel nuts. Hence, our suspicion of foreign body (betel nut) aspiration became stronger. The patient was immediately taken to operation theatre for rigid bronchoscopy and three pieces of betel nut of approximately 10 x 5 mm, two from right main bronchi and one from left main bronchus, were removed. Postoperatively, patient was put on i.v. antibiotics and gradually his condition started improving and the subcutaneous emphysema also got resolved in next 5 days. Patient was subsequently discharged from the hospital on seventh postoperative day.
|Figure 1: X-ray showing subcutaneous emphysema over neck and chest (white arrows)|
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|Figure 2: Virtual 3-D CT film showing foreign body in both main bronchi (white arrows)|
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|Figure 3: CT scan showing mediastinal and subcutaneous emphysema (white arrows)|
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| Discussion|| |
Foreign bodies in trachea and bronchi manifest with respiratory distress of variable degree, pneumonia, lung abscess, bronchiectasis, and rarely pneumomediastinum. , Subcutaneous emphysema is one of the least common presentations of foreign body bronchus.  Whenever an adult patient presents with subcutaneous emphysema of neck and chest, we should include foreign body bronchus in the differential diagnosis even if history of foreign body is not available. A review of literature has shown that aspiration in distal airways can remain silent initially,  but prolonged entrapment of foreign bodies can present with complications like subcutaneous emphysema and dry cough. This type of unusual presentation is misleading and leads to delayed diagnosis and management of such cases, especially so if there is no history or suspicion of foreign body aspiration. Chest radiographs in such cases are inadequate to rule out diagnosis, as mostly the foreign bodies are quite often radiolucent.  CT scan usually with virtual bronchoscopy (VB) is essential to confirm or to rule out diagnosis in such cases.
There are few case reports mentioned in the literature in which patients presented with subcutaneous emphysema after foreign body aspiration or after self-induced vomiting. Ramodan et al.  and Valdorino et al.  have reported a single case of a two-year-old child who presented with pneumomediastinum and subcutaneous emphysema following foreign body aspiration. Detailed history including presenting symptoms of swelling of the neck, dry intractable cough, and difficulty in breathing; thorough clinical examination; and judiciously carried investigations are essential to clinch the diagnosis in such cases. The history of chewing betel nuts along with the history of seizures was the clinching factor in our case. Foreign body in lower airway is common in children but rare in an adult patient, and it is still rarer to have such patient being unaware of foreign body aspiration. In our case, the patient did not give any history of foreign body aspiration and he unknowingly aspirated foreign body during an episode of seizures. Due to altered state of consciousness during the seizure episode, he was not aware of aspiration of foreign body. In the absence of any definitive history, it is always difficult to diagnose foreign body aspiration immediately because there are no specific clinical manifestations and the classic clinical presentation with coughing, wheezing, and diminished air inflow is seen in less than 2/5 th of the patients.  After an asymptomatic silent phase, foreign body in airways presents with wide variety of complications including subcutaneous emphysema and dry cough. Jung Kim et al.  have classified various thoracic foreign bodies into three types according to their cause: type I - due to aspiration; type II - due to trauma or accident; and type III - iatrogenic cause. In children, they are mostly due to aspiration but in adults, they are usually due to traumatic or iatrogenic cause.
Development of subcutaneous emphysema after foreign body aspiration is related to a ball valve mechanism set up due to bronchial occlusion. In this mechanism, the air can flow into the lung around the object on inspiration but cannot flow out of the lung on expiration. This results in hyperaeration of the involved lung or lobe which may result in development of high pressure gradient between intra-alveolar air and perivascular interstitial connective tissue. , Alveolar or airway breach allows escape of air into the perivascular tissue around the pulmonary arteries which communicates with mediastinum from which air may ascend into the neck and chest wall. Air may also extend into retroperitoneum and epidural space. , The other valvular mechanisms which can operate in foreign body bronchus include (a) stop-valves, which arrest all flow in either direction; (b) by-pass valves, which permit a diminished flow in either direction; and (c) check valves, which permit a flow in one direction only.
When aspiration of a foreign body is clinically suspected, either because of a history of choking episode or asymmetric breath sounds or wheezing, inspiration and expiration radiographs should be obtained. However, most inhaled foreign bodies are non-radiopaque and their presence is suggested only by secondary changes including segmental or lobar collapse, air trapping in unilateral hyperlucent lung, and post-obstructive lobar or segmental infiltrates. , They are also detectable indirectly due to their effect on air flow through the airway. The finding may be subtle or absent on inspiration views; however, expiration view will demonstrate the air trapping as a unilateral hyperlucent lung that does not deflate as does the normal side. In our case, the foreign body was present in both the main bronchi which had a ball valve effect permitting air to enter the lungs but disallowing its exit, which might have increased air pressure in alveoli and led to rupture of alveoli and escape of air along the large pulmonary vessels to the mediastinum. The air then might have entered the chest and neck through different fascial planes of subcutaneous tissues.  Also, an excessive pressure at alveolar level due to continuous cough facilitates extra-alveolar migration of air in the subcutaneous tissues.
CT enhances the detection of intrabronchial foreign body and secondary parenchymal changes. Three-dimensional reconstructions including VB with endoluminal navigation is possible with recently developed multidetector-row CT which gives endoscopic view of trachea and bronchi. This enhances the diagnosis of intraluminal obstructing lesions noninvasively and helps in planning of definitive intervention. , Virtual endoscopy of the tracheobronchial system is a relatively new post-processing technique that takes advantage of the natural contrast between the airway and surrounding tissues. , VB generated from thin slice axial images provides endoscopist's view of the internal surface of the airway. Endoluminal abnormalities depicted with VB show an excellent correlation with fiberoptic bronchoscopy results regarding the location, severity, and shape of airway narrowing.  VB can thus demonstrate the presence and location of foreign body without need for anesthesia, avoiding complications associated with bronchoscopy for diagnosing a suspected tracheobronchial foreign body. 
| Conclusion|| |
Thus, we conclude that while dealing with uncommon findings like subcutaneous emphysema and dry cough, one should judiciously use imaging modalities like X-ray, CT with or without VB along with detailed history and clinical examination to reach the diagnosis of foreign body aspiration in both adults and children. High index of suspicion of foreign body aspiration should be kept in patients presenting with symptoms and signs related to airways not responding to medical management. This should be done even in the absence of any definitive history, irrespective of the age of the patient.
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[Figure 1], [Figure 2], [Figure 3]