Citation: Shimizu, R.; Sukegawa, S.;
Sukegawa, Y.; Hasegawa, K.; Ono, S.;
Fujimura, A.; Yamamoto, I.; Ibaragi,
S.; Sasaki, A.; Furuki, Y.
Subcutaneous Emphysema Related to
Dental Treatment: A Case Series.
Healthcare 2022, 10, 290. https://
doi.org/10.3390/healthcare10020290
Academic Editor: Daniele Giansanti
Received: 7 December 2021
Accepted: 28 January 2022
Published: 1 February 2022
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Case Report
Subcutaneous Emphysema Related to Dental Treatment:
A Case Series
Rieko Shimizu
1
, Shintaro Sukegawa
1,
* , Yuka Sukegawa
1
, Kazuaki Hasegawa
1
, Sawako Ono
2
, Ai Fujimura
1
,
Izumi Yamamoto
1
, Soichiro Ibaragi
3,4
, Akira Sasaki
3
and Yoshihiko Furuki
1
1
Department of Oral and Maxillofacial Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-Machi,
Takamatsu 760-8557, Kagawa, Japan; de421021@s.okayama-u.ac.jp (R.S.); yuka611225@gmail.com (Y.S.);
de421040@s.okayama-u.ac.jp (K.H.); sugar.x.48@gmail.com (A.F.); iyamamoto8408@gmail.com (I.Y.);
furukiy@ma.pikara.ne.jp (Y.F.)
2
Department of Pathology, Kagawa Prefectural Central Hospital, Takamatsu 760-8557, Kagawa, Japan;
de19008@s.okayama-u.ac.jp
3
Department of Oral and Maxillofacial Surgery, Okayama University Graduate School of Medicine, Dentistry,
and Pharmaceutical Sciences, Okayama 700-8525, Okayama, Japan; sibaragi@md.okayama-u.ac.jp (S.I.);
aksasaki@md.okayama-u.ac.jp (A.S.)
4
Advanced Research Center for Oral and Craniofacial Sciences, Okayama University Graduate School of
Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8525, Okayama, Japan
* Correspondence: gouwan19@gmail.com; Tel.: +81-87-811-3333; Fax: +81-87-802-1188
Abstract:
Cervicofacial subcutaneous emphysema (SE) is primarily caused by dental treatment
introducing gas into the subcutaneous tissue. Air rapidly dissects into the subcutaneous tissue with
face and neck swelling, leading to respiratory distress, patient discomfort, and chest pain. Computed
tomography (CT) can detect spreading SE patterns. However, the true volume of SE and the degree
of air changes in the body over time remain unknown. We evaluated the healing process of SE
and the temporal changes in the volume of emphysema in three cases detected using our hospital’s
electronic health record systems based on inclusion and exclusion criteria over the past 10 years, with
CT and three-dimensional (3D) images. The first case was a 46-year-old woman who presented with
complaints of swelling from her right eyelid to the neck and clavicles, pain on swallowing, respiratory
distress, and hoarseness. The second case was a 35-year-old man who presented with complaints
of swelling over the face. The third case was a 36-year-old man who presented with complaints of
swelling from the left cheek to the neck. CT revealed SE and pneumomediastinum in all cases. All the
patients were administered an antibacterial drug. The CT and 3D images showed an improvement
in emphysema 3 days after the onset, with more than half of the volume reduction in emphysema.
This made it possible to evaluate the changes in the air content of SE. Observation with CT until the
healing process of SE is completed is crucial, and 3D images also help evaluate changes over time.
Keywords: subcutaneous emphysema; dental treatment; computed tomography; 3D images
1. Introduction
Cervicofacial subcutaneous emphysema (SE) is known to be caused by the invasion
of gas into the subcutaneous tissue. It is also caused by trauma such as facial fractures,
intraoral trauma, traumatic destruction of the chest wall or the airway gastrointestinal
tract, and dental treatment [
1
–
4
]. Jones A. conducted a literature review from 1993 to 2020
and found that dental extraction often preceded the onset of SE (54% of cases) in dental
treatment. Most cases were iatrogenic, 51% were due to air turbines, 9% were due to
air syringes, and factors such as nose-blowing accounted for 10%. When gas enters the
subcutaneous tissue gap, its spread rate is high and is accompanied by the swelling of
the face and neck, along with dysphagia, chest tightness, and dyspnea in some cases [
5
].
Computed tomography (CT) involves a small amount of exposure for the imaging, but it
provides useful information for lesion location and differential diagnosis [
6
,
7
]. Using this
Healthcare 2022, 10, 290. https://doi.org/10.3390/healthcare10020290 https://www.mdpi.com/journal/healthcare
