Odma śródpiersiowa jako następstwo izolowanego urazu twarzoczaszki

Introduction

Post-trauma, oral maxillofacial injuries contribute to a substantial number of cases admitted to emergency departments [1]. Injuries may include bone fractures of the cranium, facial bones, and cranial nerves, as well as associative dental, oral mucosa, soft tissues, ears, nose and eyes injuries [2]. Epidemiological findings dictate gender as a critical risk factor in oral maxillofacial injury, where young adult males are more susceptible to such afflictions [2]. Occurrences in males are seen predominantly in the third decade of life [2, 3]. The leading contributing factor is a violent assault, followed by motor vehicle accidents, falls, and sports-related calamities [2, 3]. Several case reports discuss rare complications of subcutaneous emphysema, and pneumomediastinum, secondary to isolated oral-maxillofacial trauma. Analogous atypical secondary manifestations resulting from isolated oral-maxillofacial trauma are described in this case report.
The presented case study documents a 23-year-old male admitted to the emergency department after a beating while intoxicated, with the fracture of the ramus of the mandible from the angle to the coronoid process without displacement and fracture of the posterior wall of the left maxillary sinus. Subcutaneous emphysema and pneumomediastinum were observed secondary to the isolated trauma. Pneumomediastinum, also known as mediastinal emphysema, is a condition where the air is entrapped in the mediastinum [4, 5]. The manifestation of subcutaneous emphysema and pneumomediastinum to facial trauma are said to be rare occurrences [4]. In this atypical manifestation, the air can enter through the sublingual from a mandibular fracture and extend towards the retropharyngeal space, including the mediastinum [4–9]. Due to facial trauma, pneumomediastinum is clinically minimally presented and appears in radiographs as leaked air in the mediastinal pleura [4]. Limited surgical literature documents the correlation between post-oral maxillofacial isolated traumas and the manifestations as presented in this case study.

Case report

Herein, we present the case study documenting a 23-year-old male admission to the emergency department of the University Clinical Hospital in Poznan, Poland, due to a beating. While establishing a rapport, the patient claimed he was intoxicated during the incident; however, he did not lose consciousness. As a result of the beating, the patient experienced epistaxis. The patient’s medical history was unremarkable. On admission, he complained of localized pain in the trauma area, inability to eat and pain in the vicinity of the thyroid cartilage. Symptoms started the day before admission.
Upon admission, the patient was subjected to an extensive physical examination, which revealed no Hamman’s sign. Two deviations were observed during the physical examination. The first one was that the patient had difficulty with mouth opening (trismus). The second area of concern was the left cheek to the thyroid cartilage, where subcutaneous emphysema was noted.
The patient was sent for a panoramic radiograph, and computed tomography (CT) scans following the physical examination. The panoramic radiograph determined that the patient had a fracture of the ramus of the mandible from the angle to the coronoid process without displacement (Figure 1). In addition, neck and craniofacial CT showed a fracture of the posterior wall of the left maxillary sinus with small invagination to the lumen of the sinus and confirmed large emphysema of soft tissue of the left mesenteric space, left infratemporal fossa and both parapharyngeal spaces to the mediastinum. The chest CT scans demonstrated the presence of pneumomediastinum in the upper and lower mediastinum to the level of trachea furcation (Figure 2).
Following the examination and diagnosis, the patient was consulted by a thoracic surgeon. The thoracic surgeon advised hospitalization and antibiotic therapy. Treatment of pneumomediastinum involved administration of amoxicillin with clavulanic acid three times daily for 10 days. The patient refused hospitalization and decided to go home. Two days after the initial visit, a chest X-ray was performed, which revealed no sign of pneumomediastinum. As for the observed fractures, 2 days after hospital admission, intermaxillary fixation was placed. In addition, a panoramic radiograph after the placement of intermaxillary fixation was taken.
Four weeks from the post-trauma examination, a follow-up appointment was scheduled and revealed no deviations. During the post-trauma examination, the intermaxillary fixation was removed. It was also concluded that there was no indication for surgical intervention after the patient went to the thoracic surgery outpatient clinic. 51 days post-admission, a control orthopantomogram was also taken for the patient. Post intermaxillary fixation removal, the control orthopantomogram revealed no deviations; the recovery was also uneventful.

Discussion

The clinical presentation of pneumomediastinum or mediastinal emphysema resulting from facial trauma is a rare occurrence [6]. Limited surgical literature has documented the correlation of post-oral maxillofacial fracture mediastinal and cervical emphysema manifestation [4–10]. Pneumomediastinum sequelae of induced maxillofacial trauma remain rare and are infrequently associated with complications, including but not limited to pneumothorax, mediastinitis, and airway obstruction [6–10]. Herein, we present an atypical case of pneumomediastinum a consequent to the fracture of posterior wall of the left maxillary sinus with small invagination to the lumen of the sinus. Etiologically analogous clinical cases provide supporting literature of pneumomediastinum manifestation secondary to maxillofacial facial trauma, emphasizing pneumomediastinum resulting from maxillofacial fractures. The literature reports rare maxillofacial injuries, where zygomaticomaxillary complex fractures, nasal-orbital-ethmoid fractures, orbital blow-out fractures and isolated maxillary sinus fractures have also induced the development of cervical and mediastinal emphysema [6].
Identifying symptoms and radiological findings of this patient alluded to post maxillofacial trauma air spread causing subcutaneous emphysema, and pneumomediastinum. All complications mentioned earlier, in this case, are exclusively due to facial blunt force trauma the patient reported during his beating. The physical examination noted subcutaneous emphysema in the left cheek area to the thyroid cartilage. Associated signs in the diagnosis of subcutaneous emphysema are crepitus on palpation, visible edema, and swelling without significant soreness [4, 10]. The patient’s diagnosis of occult pneumomediastinum was verified by CT scans. The CT findings showed the presence of air, producing large emphysema of soft tissue, located in the left mesenteric space, left infratemporal fossa, both parapharyngeal spaces spreading downwards around vascular bunches to the mediastinum. In analogous manifestations, air enters through the sublingual from a mandibular fracture and extends towards the retropharyngeal space, involving the mediastinum in the process [4–10]. Pneumomediastinum manifests from the presence of mediastinal emphysema, as demonstrated in this case study [4–10]. In facial trauma, clinical pneumomediastinum is minimal and appears in radiographs as leaked air in the mediastinal pleura [4, 9]. As seen in this case, CT diagnostic scans showed pneumomediastinum in the upper and lower mediastinum to the level of trachea furcation.
The examined patient’s development of subcutaneous emphysema, and pneumomediastinum is due to air spread. The entrance route can be hypothesized as through the fracture of the posterior wall of the left maxillary sinus. The distribution from the maxillofacial region can occur through different air pathways. Four prominent routes for air spread in the mediastinum include a defect in the tracheobronchial tree, fascial spaces of the head and neck, through the diaphragmatic hiatuses retroperitoneal space, and the interstitial tissues of the lung [6]. Sansevere et al. reports a detailed, plausible route of air spread causing pneumomediastinum from isolated oral-facial trauma [6]. As examined in this case, forced air through isolated facial injury may enter the parapharyngeal and retropharyngeal space. The air can disseminate further into the prevertebral potential space and fascial planes, causing emphysema in the face and mediastinum.
Pneumomediastinum resultant complications are self-limiting entities commonly benign as entrapped air will be reabsorbed from the mediastinum with time [4–10]. However, the diagnosis and proper treatment of these rare manifestations is vital in preventing the escalation of compulsory symptoms, such as rhinolalia, chest pain, labored breathing, and cardiopulmonary distress [4–10]. A complete diagnostic examination, including neck, craniofacial and chest CT scans of the patient, is required to detect pneumomediastinum. Common symptoms upon physical examination may appear inconclusive; for instance, frequent pneumomediastinum indication, Hamman’s sign (audible mediastinal crepitation), was not reported in this patient. Hence, a radiological examination is recommended to rule out plausible pneumomediastinum in oral maxillofacial injuries. Pneumomediastinum was treated first, prior to placement of intermaxillary fixation, to secure proper airway management. Prophylactic antimicrobial therapy of amoxicillin and clavulanic acid was administered to aid in fracture reduction and minimize the spread of the mediastinal emphysema. The prophylactic antibiotic administration is recommended in maxillofacial injuries as pathogens may spread from the upper aerodigestive tract into the emphysematous air pockets in the face and mediastinum [4–10]. Despite the atypicality of pneumomediastinum manifestations in oral maxillofacial isolated traumas, they are present and require vigilant diagnosis and proper treatment modalities as presented in this case (Table 1).

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References