An Overview of Subcutaneous Emphysema

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Subcutaneous emphysema is a condition in which air becomes trapped under the skin. ("Emphysema" simply means "air," while "subcutaneous" refers to under the skin.)

This type of emphysema is not like the other form of emphysema, a disease of the lungs that is often caused by smoking. Subcutaneous emphysema can result after medical procedures, surgeries, accidents, injuries, or infections.

This article will explain the symptoms and causes of subcutaneous emphysema, as well as how it is diagnosed. It will also discuss treatment options and tips for coping if you are diagnosed with the condition.

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

Symptoms

Subcutaneous emphysema is most likely to occur in the chest, neck, and face, but it can occur in any part of the body, and for many different reasons. It is more common in men than in women.

Symptoms of subcutaneous emphysema can range from mild to severe. In fact, it is possible not to have any symptoms at all. 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. However, almost all people with subcutaneous emphysema will experience:

  • Edema (swelling) in the affected area
  • Crepitus, a crackling sound when the surface of the skin is palpated (examined by touch)

Crepitus may be the sign that leads medical professionals to diagnose subcutaneous emphysema. This is also why the condition is sometimes referred to simply as crepitus or crepitus of the chest.

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 respiratory failure, pacemaker failure, problems with the airways or heart, or tension pneumothorax (a collapsed lung).

Other serious complications may include compression of the trachea, skin necrosis (death of skin tissues), compartment syndrome (swelling of muscles and other body tissues), and poor blood circulation (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.

In subcutaneous emphysema, air becomes trapped underneath the subcutaneous layer.

There are numerous underlying causes of subcutaneous emphysema, including:

  • Injuries to almost any part of the body but especially the chest, sinuses, or facial bones
  • Pneumothorax
  • Infection with necrotizing bacteria that kills skin tissue, increasing the risk of gangrene
  • Surgical trauma
  • Laparoscopic surgeries
  • Barotrauma, also called "the bends" that can occur in scuba divers. Other activities that subject a person to extreme altitude changes can also cause barotrauma.
  • 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 cardiopulmonary resuscitation (CPR)

Rarely, subcutaneous emphysema may occur for no known reason. This is referred to as spontaneous subcutaneous emphysema.

Recap

There are many possible causes of subcutaneous emphysema. These include trauma during surgery, an injury to the esophagus during the placement of a feeding tube, and some types of bacterial infections. Two symptoms that occur in all cases are edema (swelling) and a crackling sound in the area known as crepitus.

Diagnosis

If your doctor suspects you may have subcutaneous emphysema, they may order some of the following tests to aid in the diagnosis:

  • X-rays: These may be positive for a "gingko leaf sign." This describes a pattern of air along the pectorals major muscle that resembles the veins in a ginkgo leaf.
  • Computed tomography (CT): This type of 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: These procedures may be performed if the condition is thought to be the result of an injury from intubation.
  • Ultrasound: This may be used if a pneumothorax is suspected.

Edema from subcutaneous emphysema has been misdiagnosed as other conditions such as allergic reactions. However, 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 10 days without serious complications if the underlying cause is successfully treated. During this period, the air pocket is gradually reabsorbed into the body.

Controlling symptoms and any discomfort is also important. In minor cases of subcutaneous emphysema, you might not feel any discomfort. If you are uncomfortable, this may be managed with oxygen, by using abdominal binders (to compress the abdomen), or with pain medications.

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 remove 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.

Recap

If your doctor thinks you may have subcutaneous emphysema, they will perform diagnostic tests, including X-rays, a CT scan, or a bronchoscopy. Once the underlying cause is known and treated, the condition usually resolves itself in about 10 days.

Prognosis

Despite potentially deadly complications that can occur from subcutaneous emphysema, these are actually quite rare and the prognosis is good. 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. Reaching out to family members and friends as well as 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.

Summary

Subcutaneous emphysema is a condition in which air becomes trapped under the subcutaneous layer of the skin. The main symptoms are edema and crepitus. There are many possible causes, including accidental injuries during surgery, injury during the placement of a breathing tube, and certain infections. Some of the tests used to diagnose the condition include X-rays, CT scans, or bronchoscopy. In most cases, subcutaneous emphysema will resolve on its own in around 10 days once the underlying cause is treated.

A Word From Verywell

While subcutaneous emphysema can be uncomfortable and alarming, it can be reassuring to know that most of the time it goes away without any lasting effects. If you notice swelling in a certain area of your body or notice a crackling noise when you press on the swollen area, call your healthcare provider as soon as possible.

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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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