An Overview of Subcutaneous Emphysema

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Subcutaneous emphysema is a condition where air becomes trapped under the skin. Emphysema simply means "air" while "subcutaneous" is in reference to the location of air. This type of emphysema is not like other types of emphysema you have heard of, which are diseases of the lungs, and it is not caused by smoking. It can result after medical procedures, sugery, accident, injury, or infection.

Subcutaneous emphysema is most likely to occur in the chest, neck, and face since these areas of the body are so close to the lungs, but it can occur in all types of the body and for many different reasons. It is more prevalent in men than in women.

X-Ray film of subcutaneous emphysema
Subcutaneous Emphysema Right Chest.  Sopone Nawoot / Getty Images Plus

Symptoms

There is a wide range of severity when it comes to subcutaneous emphysema. In mild cases you may not experience any symptoms at all while more severe cases can lead to significant discomfort and serious complications. Symptoms of subcutaneous emphysema also vary depending on the underlying cause and where in the body it is located. Almost all people with subcutaneous emphysema will likely experience:

  • Edema in the affected area
  • A crackling sound when the area is palpated

When the surface of the skin is touched it may make a distinct crackling noise. This is called crepitus and may help medical professionals to initially suspect and then diagnose the condition. This is also why subcutaneous emphysema is sometimes referred to as crepitus or crepitus of the chest.

Based on individual circumstances other symptoms may include:

  • Sore throat
  • Neck pain
  • Difficulty breathing
  • Difficulty swallowing or speaking/voice changes
  • Distention or bloating of the abdomen

Severe cases of subcutaneous emphysema can lead to airway compromise, pacemaker failure, respiratory failure, cardiovascular compromise or tension pneumothorax.

Other serious complications may include tracheal compression, skin necrosis, compartment syndrome and even poor perfusion to the brain.

Causes

There are three layers of skin. The outermost layer is called the epidermis, beneath that is the dermis and then the subcutaneous layer which is composed mostly of fat and connective tissue. It is this layer, the subcutaneous layer, where air becomes trapped in cases of subcutaneous emphysema, although this may be an indication that air is also residing in deeper tissue layers.

There are numerous underlying causes of subcutaneous emphysema including but not limited to:

  • Injuries to almost any part of the body but especially the chest, sinuses, or facial bones
  • Pneumothorax
  • Infection with necrotizing bacteria (gangrene)
  • Surgical trauma
  • Laparoscopic surgeries carry risk since the abdomen is often filled with carbon dioxide
  • Barotrauma that occurs during scuba diving or other activity that subjects a person to extreme altitude changes
  • Accidental injury to the trachea during intubation (insertion of a breathing tube)
  • Ventilator malfunctions or issues
  • Injuries to the esophagus (often occur during the insertion of a feeding tube)
  • Bowel or esophageal perforations
  • Bag mask ventilation during CPR

Rarely subcutaneous emphysema may occur in the absence of a known cause. This is referred to as spontaneous subcutaneous emphysema.

Diagnosis

If your symptoms, particularly crepitus, and health history cause your doctor to suspect subcutaneous emphysema they may order some of the following tests to aid in the diagnosis:

  • X-rays may be positive for a gingko leaf sign (a striation of gas along the pectorals major muscle)
  • Computed tomography (CT) scan can show dark pockets of air in the subcutaneous layer and may also be helpful in identifying the source of the air
  • Laryngoscopy and/or bronchoscopy may be performed if the subcutaneous emphysema is thought to be the result of an injury from intubation
  • Ultrasound

Edema from subcutaneous emphysema has been misdiagnosed as other conditions such as allergic reactions but the presence of crepitus and the fact that there will be an absence of lip swelling with subcutaneous emphysema can help medical professionals to differentiate between these conditions.

Treatment

Subcutaneous emphysema will usually resolve in about ten days without serious complications if the underlying cause is successfully treated. The air is gradually reabsorbed. Therefore determining how the condition occurred and treating that is essential.

Controlling symptoms and any discomfort is also important. In minor cases of subcutaneous emphysema you might not feel any discomfort. More severe cases of subcutaneous emphysema can cause bothersome symptoms. If you are uncomfortable this may be managed with oxygen, by using abdominal binders or with pain medications depending on your individual circumstances.

The administration of highly concentrated oxygen is often used as a treatment since it helps the body to absorb the subcutaneous air more quickly.

Severe cases of subcutaneous emphysema may require surgical treatments or the insertion of drains. Another common treatment is to make two infraclavicular incisions on each side (these are deep incisions made below the clavicle bone). Sometimes the insertion of a chest tube is also necessary to evacuate the air. In some cases small incisions may be made in other parts of the body or needles or catheters may be used to get rid of excess air.

Prognosis

Despite potentially deadly complications that can occur from subcutaneous emphysema these are actually quite rare and the prognosis is good. The majority of cases require no treatment but resolve on their own. One study showed that among all grades of severity the mean hospitalization period of patients with subcutaneous emphysema was 16 days.

Coping

Mild cases of subcutaneous emphysema may not be bothersome but in other cases swelling of the face or tissue necrosis can occasionally cause changes to your appearance that can be troubling. It is important to remember that these appearance changes will improve or completely resolve in time.

Depending on the underlying cause of your subcutaneous emphysema you may be coping with other health challenges that can also be distressing. Please reach out not only to family members and friends but to your medical team for help in coping with the emotional aspects of your illness. Your medical team may be able to connect you with a support group or other resources that can aid in coping and recovery.

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  1. Aghajanzadeh M, Dehnadi A, Ebrahimi H, et al. Classification and management of subcutaneous emphysema: A 10-year experienceIndian J Surg. 2015;77(Suppl 2):673–677. doi:10.1007/s12262-013-0975-4

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