FACIAL EMPHYSEMA DURING ZYGOMATIC BONE FRACTURE REDUCTION PROCEDURE ENFISEMA FACIAL DURANTE O PROCESSO DE REDUÇÃO DE FRATURA ZIGOMÁTICA

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1 893 FACIAL EMPHYSEMA DURING ZYGOMATIC BONE FRACTURE ENFISEMA FACIAL DURANTE O PROCESSO DE REDUÇÃO DE FRATURA ZIGOMÁTICA Daniel Luiz Gaertner ZORZETTO ** Clóvis MARZOLA *** Marcos Maurício CAPELARI ** Marcelo Rodrigues AZENHA * Lucas CAVALIERI-PEREIRA * Luiz Gustavo MASSARIOLI-OLIVEIRA * * Residents of Oral and Maxillofacial Surgery, Division of Oral and Maxillofacial Surgery, Base Hospital, Bauru, São Paulo, Brazil. ** Associate Professor of Oral and Maxillofacial Surgery, Division of Oral and Maxillofacial Surgery, Base Hospital, Bauru, São Paulo, Brazil. *** Oral and Maxillofacial Surgery retired Titular professor, Division of Oral and Maxillofacial Surgery, São Paulo University, USP, Bauru, São Paulo, Brazil.

2 894 ABSTRACT During surgical procedures different accidents/complications may occur with emphysema been one of them. It happens when air is introduced into tissues under positive pressure. The treatment of surgical emphysema is conservative and antibiotic therapy is advocated, with complete recovery usually been observed. Third molars extraction and endodontic therapy are the most common relates in neck/face region. This paper describes a case of facial emphysema developed during a zygomatic bone fracture stabilization realized under general anesthesia. The tissue dissection was probably caused by a perforation presented at nasal traqueal canulla with air reaching the facial space from the zygomatic fracture site. It is important to general dentistry to know how to diagnosis and to treat facial emphysema. RESUMO Durante um processo cirúrgico diferentes tipos de acidentes e ou complicações podem ocorrer como um enfisema. Essa alteração acontece quando o ar é introduzido no interior dos tecidos sobre pressão positiva. O tratamento do enfisema cirúrgico é sempre conservador e com antibioticoterapia, com a completa reversão do quadro sendo conseguida. Extração de terceiros molares e terapia endodôntica são os relatos mais comuns encontrados na região do pescoço e da face. Este trabalho descreve um caso de enfisema facial desenvolvido durante a redução de uma fratura zigomática realizada sobre anestesia geral. O tecido dissecado foi provavelmente causado por uma perfuração apresentada na cânula naso traqueal com o ar ocupando o espaço facial do lugar da fratura zigomática. É importante para o clínico geral saber qual o diagnóstico e o tratamento do enfisema facial. Uniterms: Double lip; Hyperplasia; Syndrome of Ascher. Unitermos: Lábio duplo; Hiperplasia; Síndrome de Ascher. INTRODUCTION Post surgical subcutaneous emphysema (SE) and pneumomediastinium were first described (TURNBULL, 1900) after a tooth extraction when the patient blew a bugle. Since then, different cases have been reported (SANDLER; LIBSHITZ; MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG; FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and

3 895 VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). Emphysema is a well known complication that arises when air is introduced into soft tissues by a positive pressure and is described in facial region following restorative dentistry treatment, tooth extraction and periodontal surgery (SANDLER; LIBSHITZ; MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG; HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). This type is the most common one, however, it may reach the deep anatomic spaces such as the mediastinal space, the peritoneum, pterygomandibular, parapharyngeal, retropharyngeal and deep temporal spaces (SANDLER; LIBSHITZ; MARK, 1975; HOROWITZ; HIRSHBERG; HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). During the clinical exam subcutaneous crepitation may be felt and functional limitation is also seen at the area. The treatment of surgical emphysema is conservative with antibiotic therapy been ministrated (HOROWITZ; HIRSHBERG; FREEDMAN, 1987; GUEST; HENDERSON, 1991; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004 and MARZOLA, 2005). This report describes a case of facial SE that occurred during a zygomatic bone surgical reduction procedure in a 13-year-old boy. CASE REPORT A 13-year-old boy presented to the Oral and Maxillofacial Surgery Department, Base Hospital, Bauru, São Paulo, Brazil with a complain of numbness in the left facial region and dyplopia. He reported of been hit during a soccer game 2 days ago. At clinical and radiographic exams was observed a zygomatic bone fracture classified as type 6 (DINGMAN, 1964). Under general anesthesia at Base s Hospital surgery facilities, a temporal region approach was made (GILLIES; KILLER; STONE, 1927) in association with an infra orbital incision to reach the left inferior orbital rim to fix the zygomatic bone with titanium plate and screws devices. During the fixation procedure severe SE was noted in the left facial region (Figure 1). No anesthesia failure was presented neither the electrocardiography showed any alteration on ST-T segment. The surgery was completed and antibiotics were administered for seven days after surgical procedure. Anti-inflammatory and analgesics medication was prescribed also. The post-operative course was uneventful with totally recovered of the emphysema after 6 days with no alterations noted (Figure 2).

4 896 Figure 1 Subcutaneous facial emphysema after the surgical procedure. Figure 2 Post-operative facial appearance after 14 days. DISCUSSION Emphysema is a well-known complication following surgical procedures such as restorative dentistry, periodontal surgery and oral and maxillofacial surgery (SANDLER; LIBSHITZ; MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG; FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). The advent of the air rotor drill increased this situation that arises when air is introduced into soft tissues under positive pressure. Almost 8% of patients who entered an emergency room with paranasal sinus fracture an emphysema situation can be observed (BRASILEIRO; CORTEZ; ASPRINO, 2005). In this case, the patient did not present a SE during the first evaluation, but developed this complication at surgical procedure. Different cases of emphysema following tooth extraction or dental therapy are reported, but none describing surgical emphysema developed during a facial bone reduction procedure. The emphysema showed in this paper did not extend to the deep spaces as the mediastinal one (SANDLER; LIBSHITZ; MARK, 1975; HOROWITZ; HIRSHBERG; FREEDMAN, 1987; NOBLE, 1972; CAPES; SALON, WELLS, 1999; GUEST; HENDERSON, 1991 and HEYMAN; BABAYOF, 1995) and was not caused by an air turbine dental hand

5 897 piece (SANDLER; LIBSHITZ; MARK, 1975; HOROWITZ; HIRSHBERG; HENDERSON, 1991; SEKINE; IRIE; DOTSU et al., 2000; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006) or during a dental treatment (TURNBULL, 1900; SNYDER; ROSENBURG, 1977; HEYMAN; BABAYOF, 1995; PENNA; NESHA, 2001; MARZOLA, 2005 and VALLARELLI; SOUZA- SILVA; MARQUES R. R. et al., 2006). The perforations to fix the titanium screws and the plate after the zygomatic bone reduction were made by an electrical drill without the use of any equipment that release under pressure air like a nitrogen cylinder. Most cases of emphysema occur during surgery procedure or within the first post operative hour and the treatment consist in the use of broad-spectrum antibiotics coverage, anti-inflammatory and pain relieve medication. Air that entered the soft tissues has a high probability to be contamined (SANDLER; LIBSHITZ; MARK, 1975; SNYDER; ROSENBURG, 1977; HOROWITZ; HIRSHBERG; HENDERSON, 1991; HEYMAN; BABAYOF, 1995; SEKINE; IRIE; DOTSU et al., 2000; PENNA; NESHA, 2001; RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004; MARZOLA, 2005 and VALLARELLI; SOUZA-SILVA; MARQUES R. R. et al., 2006). In our case the emphysema occurred during the surgical procedure disappearing at 14 post-operative day and a second generation cephalosporin were used during 7 days after the surgery. The clinical signs and symptoms of emphysema include regional swelling, dyspnea, dysphagia, dysphonia, weaknesses, crepitus on palpation, electrocardiography alteration and minimal pain (HOROWITZ; HIRSHBERG; FREEDMAN, 1987 and RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004). Radiographic exams showed a soft tissue expansion with radiolucids areas near to the soft tissues (RIBEIRO JR; GONÇALEZ; PADOVAN et al., 2004). Regional swelling, crepitus on palpation and no pain was observed at the present study. Since emphysema is caused by the introduction of air under pressure into the tissues there is a doubt about the origin of the emphysema related in this case. The most acceptable hypothesis is that the nasal traqueal canulla could have a small perforation and during the surgical procedure the air was introduced to maxillary sinus and reached superficial facial space from the zygomatic fracture site causing the facial swelling. CONCLUSION The report showed classical emphysema of facial spaces during a zygomatic fracture surgery procedure. The emphysema is an uncommon complication but it is possible to occur during an oral and maxillofacial surgery. Its characteristics should be observed to not mistake with post operative edema or rapidly expanding hematoma. We believe that patients with emphysemas symptoms should be routinely seen to exclude the possibilities of further complications.

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