Severe Respiratory Distress From Subcutaneous Emphysema After Tracheocutaneous Fistula Repair: A Case Report

Abstract

Subcutaneous emphysema results from air or gas being forced into the fascial spaces of subcutaneous tissue. Once the air or gas has entered the fascial spaces, it travels along connective tissue causing a mass effect and swelling. This rare complication usually presents with mild severity during the immediate postoperative period following surgical procedures of the head or neck regions and self-resolves with conservative treatment. However, a range of presentations are possible to the point of being life-threatening, as in the present case in which the mass effect on the airway was severe. This report focuses on a life-threatening case of subcutaneous emphysema in a three-year-old male patient who was recovering in the postanesthesia care unit following tracheocutaneous fistula closure. Prompt recognition of the root cause, urgent placement of a new tracheostomy tube for restoration of the airway, and administration of sedation to minimize the amount of air forced into the fascial spaces were crucial for a safe patient outcome. This discussion highlights the importance of awareness of this complication, timely rescue management, and strategies for intraoperative anesthetic management to prevent and mitigate triggering factors.

Keywords: airway obstruction; ent complication; pacu; respiratory distress; tcf closure.

Figure 1. Frontal supine radiograph of the chest revealing severe subcutaneous emphysema of the soft tissues of the face, neck, and chest wall (red arrows). The mass effect of the subcutaneous emphysema resulted in severe airway obstruction.