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Oral Surgery

Authors: Dr. Abdul Hameed, Dr. V. Jeevan Prakash, Dr. Rabiya A H.

Abstract:
Orbital emphysema is a relatively rare complication during routine dental procedures. This occurs following forceful entry of air into the periorbital soft tissue spaces. Its incidence is increasing because of improper use of routine air pressure instruments.

Purpose:
Majority cases go unnoticed or undiagnosed. Our purpose is to make the dentists aware of this condition, to highlight other possible rare causes such as forceful nose blowingor sneezing, it’s effective management and preventive measures.

Patient and method:
We report 2 cases of Periorbital emphysema during the surgical extraction of mandibular 3rd molar.

Case 1: Periorbital emphysema due to sneezing during a routine third molar surgical procedure.
Case 2:Surgical emphysema developing because of use of high speed air rotor to cut the bone.

In both cases, there was no history of facial trauma or previous nasal surgery. Both the patients developed peri-orbital swelling and palpable crepitus. Periorbital emphysema was confirmed by clinical and radiological examination.

Results:
Both the cases were promptly diagnosed and managed conservatively with antibiotics,steroids, nasal decongestants, eye drops with the consultation of ophthalmologists and otolaryngologists.

Conclusion:
Although there are existing case reports documenting the occurrence of surgical emphysema following dental procedure, but a case of periorbital emphysema is not documented, much less attributed to uncommon etiology. This can be managed conservatively as in these cases. It is important that the potential seriousness of such a complications resulting from dental procedures are not overlooked even in cases where high speed air turbines is not used.

Introduction:
Surgical emphysema is defined as gas or air trapped in the subcutaneous tissue. Surgical emphysema is a known complication during dental procedures however periorbital emphysema or oedema following a dental procedure makes the case a very scary scenario to encounter but makes it an interesting case report.

Orbital emphysema is the abnormal presence of air in the tissue around the orbit1. Trauma is the most frequent cause of orbital emphysema however, orbital emphysema may also occur spontaneously as a complication of barotrauma, infection and surgery.2 Medial wall particularly the Lamina papyracea is the most common site of bony defect for passage of air from paranasal sinuses.In dentistry, it may appear that, the use of high pressure air during various dental procedures or difficult long extractions or iatrogenic injuries increase the incidence.

It is usually a benign, self-limiting phenomenon which resolve on its own without compromising ocular function. But in case if excessive amount of air accumulate within the orbitit may lead to loss of vision if not recognized and treated promptly. In this presented case reports, we are describing two patients with no history of trauma one who developed orbital emphysema following forceful nose blowing during the dental procedure and second because of use of airotor to section the tooth. The purpose of this presentation is to stress the aetiology and early recognition of ocular emphysema and its simple and effective emergency treatment in order to prevent potential visual loss.

Case Report -1:
A 45 year old female was referred for surgical removal of a distoangular impacted lower right third molar. Surgery was scheduled under local anaesthesia and normal surgical protocol was followed. Under aseptic conditions, a minimal flap was raised and a micromotor handpiece was used for cutting bone and tooth sectioning. Almost immediately after tooth sectioning, periorbital swelling observed with inability to open eyes. Initially it was thought that it may be allergic reaction to anaesthetic agent and hence surgery was abandoned and intravenous antihistaminic and dexamethasone 8mg administered stat. On physical examination revealed a crepitant swelling and ptosis of the right upper eyelid with multiple air filled blisters within eye. It has also been noticed that perioperatively, the patient had been blowing her nose vigorously and sneezing several times. (Fig 1a, 1b, 1c)

fig1a Fig1b fig1c fig1d


An ophthalmologywas scheduled immediately and the visual acuity was normal for both eyes 10/10. Proptosis was not present. There was no palsy of the external ocular muscles. Pupillary reactions were normal. The intraocular pressure was normal and the sclera, cornea, lens, vitreous, retina, and the optic disc were bilaterally normal. Vitals were within the normal range. It was decided not to perform any needle aspiration and hence patients were decided to be treated on an outpatient basis.

Ice-pack application, lying down with resting towards the pathologic side, and avoidance of nose blowing or straining (Valsalva manoeuvres) as shown in Fig 2dand sneezing were to be avoided.

  • Empirical antibiotics (Amoxicillin + Clauvulanic acid, 625mg tid for 5 days)
  • Nasal decongestant sprays ( Oxymetazoline, 2 drops per nostril every 6thhrly)
  • Non-steroidal anti-inflammatory drug (Diclofenac Sodium + Serropeptidase)


was prescribed. Twenty-four hours later, on follow-up, the swelling had almost disappeared.
Patient was regularly followed and five days later there was no clinical sign of emphysema in this case.

Case Report -2
A 28 year old male patient was referred for further management to us by a private dentist with a sudden onset of swelling on the right side of face with periorbital region after the surgical removal impacted mandibular third molar. (Fig 2a)

On taking a detailed history and discussions with the referring dental surgeon it was found that airotor handpiece has been used to cut the bone and teeth.

Clinical examination revealed inability to open his right eye due to severe periorbital oedema and surgical emphysema of right side of face and submandibular region but not extending into the neck. There was palpable crepitus suggestive of surgical emphysema.

Radiographs of the paranasal sinuses view were requisitioned, which revealed foci of Periorbital air density on the pathologic side, suggestive of orbital emphysema.(Fig-2b).

Similar protocols for ophthalmology consultation were followed. The patient was given a stat dose of intravenous steroids and antihistamine. He was started on prophylactic antibiotics and kept under observation to see the further expansion. The patient showed signs of satisfactory recovery and partial opening of his eye after 10 hours. After 24 hours he showed significant recovery with decreased periorbital oedema, surgical emphysema and was discharged home on oral antibiotics. He recovered completely in about 7 days.

Discussion:

fig2a fig2b dis-3.1 dis-3


Subcutaneous emphysema by itself of late is an uncommon complication in routine dental procedure. Subcutaneous emphysema occasionally complicates dental procedures as peri-orbital and/or mediastinal emphysema, and rarely, in more serious cases, pneumothorax, pneumopericardium, pneumo- peritoneum or orbital emphysema.The causes of surgical emphysema include traumatic facial injury, rupture of pulmonary bulla, prolonged surgical procedure, and direct injection of air during dental procedure. 3 Maximum numbers of cases were associated with the use of air-driven hand pieces during dental procedures. It should be noticed that surgery is not the only procedure at risk for the development of subcutaneous emphysema, as it has also seen during restorative procedures, crown preparation, and endodontic therapy. 4 During surgical procedures elevation of a large flap along with the use of airotor hand piece can raise the risk of emphysema, especially during third molar surgery. Air can diffuse into various facial spaces from the molar-retromolar region, and reach the mediastinum downward and upward to the periorbital region by dissecting along the visceral space. 5 Depending upon the cause, subcutaneous emphysema associated with dental procedure categories into four categories.

schema
  • Those incited by the patient coughing or straining,
  • Those in which air is forced directly into the tissues e.g. by an air turbine or syringe
  • Those following a prolonged procedure e.g. third molar or periodontal surgery,
  • Those with no identifiable cause.


Isolated Orbital emphysema is usually a complication of orbital fracture which usually results from direct injury. 6 A few cases of orbital emphysema have been reported due to indirect injury like nose blowing7,post-surgical sneezing and pressure change during air travel. Emphysema in the orbital region is found in three sites – (a) Eye lids (b) orbit (c) lids & orbit combined.

Similar to the reported cases in literature we have cases of orbital emphysema, in case no2, it is because of the use of air turbine handpiece during third molar surgery, where as in case no1We believe that orbital emphysema is occurred because of increased intranasal pressure due to closing the nares with her fingers during forceful nose blowing (sneezing) during the surgical procedure (valsalva manoeuvres).A forceful expiratory effort can create significantly elevated intranasal pressure and fracture of thin medial bony wall acts as two-way valve so air can escape through this fracture site freely into the orbital space. The diagnosis of orbital emphysema is usually made by history alone, supported by results of clinical examination and confirmed with radiographs and CT scan (Fig 3). Usually emphysema resolves by its own in few days to week without any complications. 8Nevertheless, orbital emphysema can cause ischemic optic neuritis and central retinal artery occlusion and may lead to visual loss according to the severity of the condition. 9 The management depends on the emphysema extent and the severity of the symptoms. Hunts and co-workers classified orbital emphysema into four stages (table-1). Management of most orbital emphysema includes close observation and conservative treatment with Nasal decongestants, antibiotics and steroids. The role of antibiotics is not clear, the use of prophylactic antibiotic is just to avoid infection from contamination if at all it occurred. In all cases instructions must be given to the patient against nose blowing, sneezing, diving and flying and to refrain from performing a Valsalva manoeuvre for 7–10 days. With this management alone, most of the cases resolve spontaneously in two to three weeks.10

In emergency cases, Quick decompression with lateral canthotomy /cantholysis and orbital decompression, under water needle aspiration by using 24 gauge needle, bony decompression, or a combination is indicated 11. indication for invasive procedure are when orbital emphysema shows signs of pressure effect like restricted ocular motility, sluggish pupillary reaction, disc oedema or decreased visual acuity, air drainage and/or direct decompression should be considered.No invasive procedure have been conducted in our patients.

Stages of Orbital Emphysema
Stages

Criteria

Remark

I No proptosis/dystopia, no loss of vision, no increase in intra ocular pressure, no central retinal artery occlusion. Are very common and are easily recognized by radiographs
II As in stage I, except proptosis/dystopia is present. Requires CT to rule out other orbital lesions
III Proptosis/dystopia is present, loss of vision, possible rise in intraocular pressure, no central retinal artery occlusion. Requires emergency CT to locate air for needle aspiration
IV All of the above are possible including central retinal artery occlusion. Requires rapid orbital decompression which should not be delayed


Conclusion:
Subcutaneous emphysema is a potential unexpected complication of dental procedures because of various reasons iatrogenic or unpredictable causes. Subcutaneous emphysema can have potentially serious complications, in case if it extends up to the orbit it may lead to loss of vision and if reaches mediastinum threats life. When subcutaneous emphysema does occurs, it must be quickly diagnosed, understood, and effectively managed to reduce the incidence of further complications. Prevention of emphysema requires adherence to well-accepted protocols of the particular treatment. In case of surgery minimal flap elevation with firm but gentle retraction of mucoperiosteal flaps protects soft tissues from cutting instruments, preserve muscle attachment as far as possible. Moreover, air turbine high-speed hand-pieces should be avoided. It is preferable to use a contra-angle multiplier handpiece, which does not use a flux of high speed air for movement.

References:

  1. Singh M, PhuaVM, Sundar G. Sight-threatening orbital emphysema treated with needle decompression.Clin Experiment Ophthalmol 2007 May-Jun; 35(4): 386–7.
  2. BurmJS, Chung CH, Oh SJ. Pure orbital blowout fracture: New concepts and importance of medial orbital blowout fracture.PlastReconstrSurg 1999; 103:1839-1849.
  3. Shovelton D: Surgical emphysema as a complication of dental operations. Br Dent J 1957, 102:125-129.
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  8. Rowe NL, William LI, Fractures of zygomatic complex and orbit. New York: Rowe and William’s Maxillofacial Injuries; 2nd edition. Churchhill Livingstone.1994.
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  11. Lee SL, Mills DM, Meyer DR, Silver SM. Orbital Emphysema.Ophthalmology 2006; 113:2113.e1–e2.