Acute Hyponasality (Closed Rhinolalia) and Craniomaxillofacial Fracture Suggest the Coexistence of Retropharyngeal Emphysema and Pneumomediastinum

Abstract

Pneumomediastinum (PM) implies an abnormal condition where a collection of free air or gas is entrapped within the fascial planes of mediastinal cavity. It is considered as benign entity, but an uncommonly seen complication of craniofacial injuries. We report a case of a 63-year-old male patient with the presenting sign of closed rhinolalia who was diagnosed with retropharyngeal emphysema and PM due to a linear and nondisplaced fracture of midface. The patient cited multiple efforts of intense nasal blowing shortly after a facial injury by virtue of a motorcycle accident. He was admitted in our clinic for closer observation and further treatment. The use of a face mask for continuous positive airway pressure was temporarily interrupted, and high concentrations of oxygen were delivered via non-rebreather mask. Patient's course was uncomplicated and he was discharged few days later, with almost complete resolution of cervicofacial emphysema and absence of residual PM in follow-up imaging tests. Closed rhinolalia (or any acute alteration of voice) in maxillofacial trauma patients should be recognized, assessed, and considered within the algorithm for PM and retropharyngeal emphysema diagnosis and management. For every single case of cervicofacial emphysema secondary to facial injury, clinicians should maintain suspicion for retropharyngeal emphysema or PM development.

Keywords: cervicofacial emphysema; facial trauma; pneumomediastinum; retropharyngeal emphysema; rhinolalia; voice.

Fig. 1

Scattered and lucent streaks owing to the presence of free air in the patient's neck.

Fig. 2

( a ) The source of air leakage: the anterior maxillary wall. ( b and c ) The extensions of the air to various sites and spaces of cervicofacial region.

Fig. 3

The air collections within the subcutaneous tissue of the left anterior chest wall (yellow arrow), behind the sternum (green arrow), and between the left common carotid and subclavian artery (red arrow) in transverse view.

Fig. 4

( a , b , and c ) Depiction of the air collections of both maxillofacial and thoracic regions after 3D reconstruction.