Case (55)

[Admin]

15 months old boy in our ITFC program become defaulter after developing watery diarrhea & his mother took to a lady in her village which extracted 2 of his teeth including first molar as a traditional treatment for diarrhea.

Then the child developed swelling on the lower jaw which rapidly descended downward to the neck & then anterior chest.

The mother brought the child back to the ER department with difficulty breathing, nasal flaring, chest indrawing, swelling of the neck & anterior chest.

O/E: The child is dyspnic, using his accessory muscles for breathing with fullness of neck which changed the sound of his cry.
No signs of dehydration & Vital signs are normal apart from RR: 68/min
No enlarged lymph nodes in the neck
Tonsils are not enlarged & there is no membrane on it.
Chest is clear with normal air entry.
No other abnormalities detected in other systems.

The swelling is not hot, not tender, not erythematous and has crackling feel to the touch.
No history of trauma, operations or allergic reactions.
No past history of similar condition.

Investigations:
•X-ray showed soft tissue radiolucent striations of the neck & lateral sides of the chest but the CXR is within normal (No signs of pneumothorax or rib fracture)
•Urine test is normal

Questions:
1- What is your diagnosis?
2- Please explain the possible mechanism of this condition?
3- What is your plan for treatment?

N.B: You can request further information about this patient.

[Mustafa]

Salam,

1. Subcutaneous emphysema as a complication of tooth extraction ( Ebinyo, a from of infant oral mutilation, widely practiced in rural areas in eastern Africa. which traditional healers and other village elders extirpate the primary canine tooth follicles of infants by using crude, often unsterilized, instruments or utensils. Traditional folklore suggests that the underlying tooth follicles, thought to resemble worms, are the cause of high temperature, vomiting, loss of appetite and diarrhea in infants)

2. in this case according to the literature, onset of iatrogenic subcutaneous emphysema of face and neck in oral cavity surgical approaches may occur due to aggressive technique and inappropriate equipment

3. Treatment of subcutaneous emphysema varies according to level of severity and to docotors' expertise. Most cases of subcutaneous emphysema are solved after two or three days of supportive treatment ( such as intravenous fluid and prophylactic antibiotics) and residual swollen is usually minimal after 7-10 days of observation.


Hope to have answered correctly

salam

[Admin]

Thanks dr.mustafa for your correct diagnosis.

It is a rare complication of tooth extraction (subcutaneous emphysema)
The Extrapulmonary causes of subcutaneous emphysema are:
1-fractures of facial bones
2-injuries of paranasal sinus
3-Dental procedures (Our case)

The patient present with sudden swelling and feeling of pressure.
the clinical signs include: swelling with crepitus (absence of erythema, pain or palpatory tenderness).
the cofirmative diagnosis is rentgenography which shows radiolucent striations in soft tissue.

We have treated with this patient...
1- Oxygenation
2- Profilatic antibiotic (IV augmentin is affective)
3- Good rehydration
4- close observation

Our second plan was to drain the air using fine catheter, but fortunately the patient showed dramatic improvement & was discharged 4th day.

N.B: usually this case is misdiagnosed as an allergic reaction.

Thanks brother mustafa again.