Management of Surgical Emphysema Spreading to the Face
Surgical emphysema extending to the face represents a potentially life-threatening airway emergency requiring immediate assessment for respiratory compromise, urgent senior multidisciplinary involvement, and consideration of definitive airway management or decompression procedures depending on clinical severity.
Immediate Recognition and Assessment
Warning signs of critical airway compromise include stridor, obstructed breathing pattern, arterial oxygen desaturation, tachypnea, difficulty breathing, dysphagia, dysphonia, or palpebral closure 1, 2. Mediastinitis can occur after airway perforation and is characterized by severe sore throat, deep cervical pain, chest pain, dysphagia, painful swallowing, fever, and crepitus 1. A patient who is agitated or complains of difficulty breathing should never be ignored, even if objective signs are absent 1.
- Pharyngeal and esophageal injury are difficult to diagnose, with pneumothorax, pneumomediastinum, or surgical emphysema present in only 50% of cases 1
- Extensive subcutaneous emphysema marked by palpable cutaneous tension, dysphagia, dysphonia, palpebral closure, or associated with airway compromise and respiratory failure requires treatment 2
Initial Management Steps
Position the patient upright immediately (head-up 35 degrees or higher) to provide mechanical advantage to respiration, reduce aspiration risk, and improve oxygenation 3, 4. Administer high-flow humidified oxygen immediately to maintain oxygenation while completing assessment 3.
- Call for help immediately via local peri-arrest protocols, ensuring senior anaesthetist and senior surgeon are informed without delay 1
- Continuous monitoring must include respiratory rate and pattern, oxygen saturation via pulse oximetry, level of consciousness, heart rate, blood pressure, and temperature 3, 4
- A difficult airway trolley should be immediately available 1, 4
Definitive Airway Management Considerations
If signs of airway compromise are present, trained and experienced anaesthetists should consider emergency tracheal intubation regardless of patient location 1. Videolaryngoscopy should be considered at first attempt, with limitation of intubation attempts 1. In time-critical settings where life-threatening airway compromise is imminent, awake tracheal intubation should be considered by anaesthetists with appropriate expertise 1.
Elective surgical tracheostomy should be considered when airway patency may be compromised for a considerable period 1. The decision is informed by: (1) extent of airway compromise; (2) likelihood of postoperative airway deterioration; (3) ability to rescue the airway; and (4) expected duration of significant airway compromise 1.
- Emergency tracheostomy is often advocated for massive subcutaneous emphysema with airway compromise 5
- Tracheostomy reduces risk of glottic damage compared with long-term tracheal tube use, particularly important if laryngeal edema is present 1
Decompression Procedures for Extensive Emphysema
For extensive subcutaneous emphysema without immediate airway compromise, subcutaneous drainage provides effective, simple, and safe management 2, 5. A large-bore (26 French) fenestrated intercostal catheter can be inserted as a subcutaneous drain and maintained under low suction (-5 cm H₂O) for 24-48 hours 2.
- Subcutaneous drains provide effective decompression of head and neck areas, markedly reducing airway pressure and subcutaneous air 5
- Alternative methods include multisite subcutaneous drainage, infraclavicular "blow holes" incisions, or increasing suction on an in situ chest drain 2
- Minimally invasive open-window thoracostomy using wound protector/retractor and three-sided taping can prevent air from entering subcutaneous space while draining trapped air 6
Pharmacological Adjuncts
Intravenous dexamethasone and tranexamic acid should be considered 1. Dexamethasone may improve upper airway obstruction and edema, though effects are not immediate 1. For inflammatory airway edema from direct airway injury, administer steroids equivalent to 100 mg hydrocortisone every 6 hours, starting as soon as possible and continuing for at least 12 hours 4.
- If upper respiratory obstruction or stridor develops, administer nebulized adrenaline 1 mg to reduce airway edema 4
Location of Care and Monitoring
Transfer to operating theatre, post-anaesthesia care unit (PACU), or ICU for close observation should be considered if patient is stable but ongoing concerns exist 1. Trained staff should nurse the patient until airway reflexes have returned and patient is physiologically stable, with one recovery nurse per patient and never fewer than two personnel in recovery 1.
- An appropriately skilled anaesthetist must be immediately available 1
- Good communication is essential, with clear verbal handover and written instructions available for recovery and ward/HDU 1
- In high-risk cases, on-call team should be briefed and written airway management plan should be in place 1
Common Pitfalls to Avoid
Never leave the patient unattended once respiratory distress is identified 3. Avoid flat or Trendelenburg positioning in patients with respiratory distress, as this worsens gastric pressure on diaphragm and aspiration risk 3. Pulse oximetry alone is insufficient monitoring and should never be relied upon as sole monitor 1, 4.