Virginia Research Day 2022

Medical Resident Research Case Reports

06 Severe Facial Edema Secondary To Extensive Subcutaneous Emphysema

Elizabeth Smith, DO; Paulette Bayne-Gaul, DO Corresponding author: Elizabeth.Smith2@LPNT.net

SOVAH Health Family Medicine Residency

Context: While subcutaneous emphysema is not rare, the extension of swelling into the face including perioral and periorbital regions can cause concern for alternative etiology such as angioedema or allergic reaction. Resolution of this edema however will only come with identifying pneumothorax and resolving persistent air leak. Case Report: A 58-year-old caucausian male with history of COPD presented to the emergency department reporting continuously worsening cough for 3 weeks and now with shortness of breath. Medical Hx: COPD, emphysema, sleep apnea on CPAP, hypertension, hyperlipidemia, psychosis, hypothyroidism, depression. History of urethral surgery post gonococcal infection. Family Hx: None reported. Social Hx: Inmate. Former smoker, no illicit drug or alcohol use. Pertinent Review of Symptoms : Shortness of breath. Otherwise negative.

Pertinent Physical Exam: Mild respiratory distress. Diffuse mild wheezing with decreased breath sounds to the left lung. Regular rate and rhythm without murmur. Temp 98.1, BP 102/67, P 88, RR 20, SPO2 90% room air, 97% on 2L. Pertinent Labs: WBC 12.44, pCO2 34, pO2 147, HCO3 19. Diagnosis: Spontaneous left pneumothorax with persistent air leak resulting in extensive subcutaneous emphysema into head and neck. Treatment: Following arrival and identification of pneumothorax, left sided chest tube was placed resulting in improvement in lung expansion and symptoms. Surgery was consulted and monitored progress. Air leak persisted requiring tube repositioning day 5 and VATS with pleurodesis day 6. Day 8 nursing called for rapid evaluation due to severe facial swelling. Due to periorbital and perioral swelling causing distress, prednisone, famotidine, and benedryl were given for possible allergic reaction or angioedema. Imaging however showed extensive subcutaneous emphysema.

Chest tube readjustments resulted in mild improvement but air leak persisted by day 18. CT showed linear subcutaneous emphysema extending to left hemithorax suggesting bronchopulmonary fistula. This was the likely cause of air leak with severe subcutaneous emphysema. This finding required patient transfer for evaluation by cardiothoracic surgeon. Comment: While most pneumothoraces resolve with chest tube placement, this patient, likely due to chronic lung disease, had persistent air leak. Due to this he suffered neck and facial edema which caused concern due to severity and patient distress. While his condition appeared critical he had no oropharygeal edema or worsening dyspnea. Identification of subcutaneous emphysema and treatment of likely bronchopulmonary fistula is the only definitive resolution for this source of facial edema.

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