Surgical Neck Emphysema Post Elective Tonsillectomy: Case Report and Literature Review

Abstract

Neck emphysema after tonsillectomy surgery is very rare. We present a case documenting the conservative management of a post-tonsillectomy neck swelling, accompanied by crepitus. Computed tomography revealed a large air density at the region of the right masticator space and the masseter muscle, proximal to other deep neck spaces and muscles. Further investigations of her associated symptoms resulted in an additional diagnosis of systemic lupus erythematosus. We have also explored the signs and symptoms associated with such cases, along with a discussion of the literature published on surgical emphysema post-tonsillectomy.

Introduction

Tonsillectomy is one of the most common procedures performed by otolaryngologists, ¹ with reported overall complications in adults in about 20% of cases. ² Most complications include post-operative infection, pain, and bleeding.

Subcutaneous facial emphysema is a rare post-tonsillectomy complication, first reported in the literature in 1910, occurring in both pediatric and adult patients. ^1,3 It is defined as a facial swelling due to presence of air in between the fascial plane and the connective tissues. ⁴ Although it is rare, clinicians should be aware of it and immediately manage the patients to prevent any life-threatening events such as airway obstruction or cardiac arrest due to tension pneumomediastinum. ³

Case Presentation

A 40-year-old woman, with no known chronic illness, presented to the otolaryngology clinic due to of recurrent attacks of acute follicular tonsillitis, with high grade fever and antibiotic intake, usually intravenous, occurring every few months in the last 3 years. She opted to undergo an elective tonsillectomy. The tonsillectomy was administered by the dissection method using the MiFusion® Thermal Fusion Technology ENTceps®, preventing bleeding or any undesirable complication. She had an unremarkable recovery period.

Three days later, she presented to the emergency room with swelling on the right side of her neck, associated with tenderness, and two spikes of fever. No signs or symptoms indicative of airway compromise were noted. On physical examination, the patient was afebrile with unremarkable vital signs, was well-oriented, and was not in distress or pain. Neck palpation revealed a right-side neck swelling, extending from the right preauricular area to right clavicle, with tenderness and crepitation. Examination of the oral cavity and oropharynx showed normal healing mucosa on the tonsillar bed, with no asymmetry or specific findings. Computed tomography (CT) revealed subcutaneous and deep soft tissue air densities, suggestive of surgical emphysema (Figure 1). The patient was admitted for observation and conservative management.

Figure 1.

Computed tomography shows the extent of the air densities.

The following day, the patient complained of left knee swelling and hotness, and mild cervical vertebral pain, Magnetic resonance imaging of the neck helped confirm surgical emphysema without any abnormal findings. The patient consulted a rheumatologist, who provided a differential diagnosis of systemic lupus erythematosus (SLE) and rheumatoid arthritis, necessitating further investigations. The swelling and crepitation over the right neck region resolved dramatically from Day 1 post-admission. She was discharged on Day 3 in a stable condition, with further follow-up appointments at both the Otolaryngology and Rheumatology departments. A definitive diagnosis of SLE was provided by the Rheumatology department.

Discussion

Subcutaneous emphysema has been reported as a rare complication post-tonsillectomy. The severity of the emphysema varies from mild subcutaneous emphysema to serious life-threatening airway compression, pneumomediastinum, and pneumothorax complication. ¹ The pathophysiology of this complication is still unclear, but two main theories have been proposed in the literature. The first theory describes it as an anesthesia-related complication through a laryngeal or tracheal tear, caused by the endotracheal tube intubation, hyperinflation of cuff tube, and/or high alveolar pressure ventilation. ^{5 -7} The second theory postulates a mucosal and muscular tear injury of the pharynx in the superior constrictor muscle and deep cervical fascia, through the tonsillar bed, which allows air to enter deep neck spaces. ^6,7 Emphysema presentation has been reported to occur either immediately during the operation, or in the recovery room if the injury occurred and was noted during the procedure. ^{6 -8} However, several studies have reported immediate emphysema without the operators noticing any intraoperative injury to the mucosa. ^1,5,9,10

A total of 32 case reports were included, which revealed the following findings (Table 1). Post-tonsillectomy surgical emphysema was found in 11 pediatric and 21 adults, with variation of severity between both age groups. The time of presentation was noted in 8/11 pediatric patients shortly within minutes to hours post-surgery, in comparison with 16/21 adult patients who presented with surgical emphysema between 4 hours and 4 days post-surgery. The main presented symptom was swelling, among 30 of 32 patients, followed by dyspnea, which occurred in 4 patients. Other symptoms included pain, sore throat, vomiting, retching, cough, fever, itching, and decreased neck motion. Radiological investigations used were X-rays in 26 of 32 patients, and CT in 16. Barium swallowing and fluoroscopy tests were used in four of 32 patients. Management options include antibiotics in 25 patients, followed by observation in 13 patients. Other management options used were cough suppressants, steroids, laxatives, oxygen, and intravenous fluids. Among the 32 case reports, only 3 patients required intubation, two required surgical repair, two required thoracotomy, and one required tracheostomy. The lengths of stay ranged between 4 hours and 15 days. ^{1,3 –33}

Table 1.

Published Case Report on Post-Tonsillectomy Emphysema.

Authors	Year of publish	Age/year	Gender	Comorbidities	Surgery	Symptom	Time at presentation	Radiological investigation	Management	LOS
Baker 11	1936	27	F	Peritonsillar abscess	Tonsillectomy	Cough, Swelling	1 day post-op	—	Observation	7 days
Ferguson et al. 12	1955	4	F	?	Adenotonsillectomy +exodontia	Swelling, tachycardia, pallor, dyspnea	15 minutes post-op	X-ray	Thoracotomy, transfusion	7 days
Anderson 13	1958	8	F	?	Adenotonsillectomy	Swelling, vomiting, retching, fever	Shortly after surgery	X-ray	Antibiotic	7 days
Prupas et al. 14	1977	22	M	?	Tonsillectomy	Swelling	14 hours post-op	X-ray, barium swallowing	Observation	?
Braverman et al 15	1997	22	F	?	Tonsillectomy	Swelling, sore throat, chest pain, dyspnea	2 hours post-op	X-ray, CT	Observation, Antibiotic	1 week
Miman et al. 8	2001	11	M	?	Adenotonsillectomy	Swelling	In recovery	X-ray	Suture repair of tonsillar fossa, packing, antibiotic	2 days
Nishino et al. 16	2003	55	F	?	Tonsillectomy	Swelling	8 hours post-op	X-ray, CT	Antibiotic	1 week
Marioni et al. 17	2003	34	F	?	Tonsillectomy	Swelling	5 hours post-op	X-ray, CT	Antibiotic	30 hours
Watanabe et al. 18	2004	24	M	?	Tonsillectomy	Swelling	1 day post-op	X-ray	Antibiotic	1 Week
Stewart et al. 19	2004	22	F	?	Tonsillectomy	Swelling	1 hour post-op	X-ray	Antibiotic	1 Day
Yammine et al. 20	2004	36	M	?	Tonsillectomy	Swelling, dysphagia, decreased neck motion	4 days post-op	X-ray, CT, barium swallowing	Antibiotic	7 days
Lima et al. 21	2005	25	M	Peritonsillar abscess, agitation and behavioral disorder on haloperidol	Tonsillectomy	Swelling	4 hours post-op	X-ray, CT	Observation	1 day
Patel et al. 22	2005	31	M	?	Tonsillectomy	Swelling, dyspnea	6 hour post-op	X-ray	Observation, Antibiotic	2 days
Shine et al 23	2005	7	F	OSA, AR	Adenotonsillectomy	Swelling	20 minutes post op	X-ray	Antibiotic, oxygen, intravenous fluid	5 days
Panerari et al. 9	2005	33	F	Chronic angina	Tonsillectomy	Dyspnea, stridor	Immediately post-op in operation room	X-ray	Antibiotic, intubation, surgical closure of muscular planes, tracheostomy	>5 days
Hung et al. 5	2009	37	M	?	Tonsillectomy + nasopharyngeal biopsy	Swelling, crepitus	Immediately post-op in operation room	X-ray	Antibiotic, intubation	3 days
Kim et al. 24	2010	36	F	?	Tonsillectomy	Swelling, pain	1 Day post-op	X-ray, CT	Antibiotic	1 week
Koukoutsis et al. 25	2013	21	M	Recurrent peritonsillar abscess	Tonsillectomy	Swelling, pain	First hours post-op	X-ray, CT	Observation, Antibiotic	1 week
Al Jabr I et al. 26	2013	43	M	Medically free	Tonsillectomy	Swelling	4 Days post-op	X-ray, CT	Observation, antibiotic	6 days
Yelnoorkar et al. 27	2014	18	M	Asthma	Tonsillectomy	Swelling	36 hours post-op	X-ray	Antibiotic	3 days
Bizaki et al. 4	2014	29	F	Medically free	Tonsillectomy	Swelling, sore throat, pressure	14 hours post-op	X-ray	Antibiotic	1 day
Tran et al. 3	2015	30	F	?	Tonsillectomy	Neck pain, cough	4 Days post -op	X-ray, CT, repeated CT, MBS	Observation, Antibiotic	>3 days
Erol et al. 28	2016	4	M	?	Adenotonsillectomy	Swelling, gagging, vomiting	10 minutes post-op	X-ray	Observation	4 hours
Crosbie et al. 29	2017	12	F	Acne vulgaris on lymecycline	Tonsillectomy	Swelling, pain, dysphagia	15 hours post-op	X-ray, CT	Observation, Antibiotic	3 days
Saravakos et al. 6	2017	21	M	Medically free	Tonsillectomy	Swelling	3 day post op		Antibiotic, cough suppressant, laxatives	10 days
Mahmood et al. 30	2018	40	F	History of peritonsillar abscess	Tonsillectomy	Swelling	1 day post-op	X-ray	Antibiotic, intravenous steroids	>4 days
Duvekot et al. 7	2019	22 m	M	Down syndrome	Adenotonsillectomy	Swelling, increased fluid intake	1 day post-op	CT	Antibiotic, inotropes, intravenous immunoglobulin, intubation, PICU	15 days
Shoemaker et al. 31	2019	30	F	?	Tonsillectomy	Bleeding, swelling	3 days post-op	CT, TNFS	Observation, Antibiotic	>1 day
De Coninck et al. 32	2019	3	M	OSA, OME, AR	Adenotonsillectomy +tympanostomy tube	Swelling	Few hours post-op	CT, flexible bronchoscopy	Tracheal laceration repair through thoracotomy, chest drain, antibiotic, PICU	5 days
Pannu et al. 33	2019	5	F	OSA. Asthma, neonatal abstinence syndrome	Adenotonsillectomy	Swelling, pain, itching	26 hours post-op	CT	Observation, antibiotic, cough suppressant	2 days
Jenna H. Barengo 1	2020	3	M	Down syndrome, GERD, AV canal repair, OSA, OME, possible celiac disease	Tonsillectomy, left VT insertion, EGD with biopsy	Swelling	Recovery room	X-ray, TNFS, Fluoroscopy, EUA + NG tube	Antibiotic, oxygen, surgical examination	5 days
Aleid et al. 10	2021	14	M	Medically free	Tonsillectomy	Swelling	Recovery room	X-ray, CT, repeated CT	Antibiotic, Oxygen, observation	1 week

In this case report, the patient underwent an uneventful tonsillectomy and presented 3 days post-tonsillectomy with neck and facial swelling, accompanied with tenderness. Her symptoms were associated with systemic manifestations, such as cervical neck pain and knee swelling. This was investigated by the rheumatology department and subsequently diagnosed as SLE. A literature search revealed that several case reports have observed SLE and spontaneous recurrent emphysema, pneumomediastinum, and pneumothorax. ^{34 -37} However, the correlation between these entities is unclear. We postulate that, when compared with a healthy population, SLE patients who undergo tonsillectomy are more likely to develop surgical emphysema, regardless of the pathophysiology of developing such a complication (anesthesia-related vs surgical-related).

Surgical emphysema post-tonsillectomy is a rare but potentially serious complication. Adults are more prone to develop surgical emphysema in comparison to pediatric patients, and their presentation is usually delayed. Most patients are treated conservatively with antibiotics and observation. However, some patients may require further airway establishment and surgical intervention. Further studies need to be conducted to identify the pathophysiology of surgical emphysema post-tonsillectomy and the possible correlation between SLE and the manifestation of such complications.