Skin emphysema T79.7

Skin emphysema is an accumulation of air or gas in the subcutaneous cell tissue caused by internal or external penetration of air or gas (Pfitzmann 2020).

Derouin et al. estimate the frequency of subcutaneous emphysema during endoscopic procedures in 1996 at 0.3 - 3.0 %. In tracheotomized and ventilated patients, skin emphysema occurs in 5 - 10 % of those affected (Larsen 2009).

Subcutaneous emphysema is most frequently associated with thoracic pathology (Nowak 1977).

The cause of skin emphysema can be due to:

- Trauma (Bork 2008)

- Pulmonary barotrauma (Kehl 2007)

- Iatrogenic, e.g. as a complication of laparoscopy, air filling (Pitzmann 2020), after dental procedures due to opening of the dentogingival gap or due to pressure in an alveolus (Bork 2008)

- In the case of an iatrogenic or post-traumatic pneumothorax, skin emphysema can form at the site of injury (Herold 2022)

- Spontaneous rupture of organs containing air

- In the context of gas gangrene

- After a skull fracture in which the paranasal sinuses or orbits are affected (Pfitzmann 2020).

Skin emphysema can occur in the following structures in the event of an injury:

- Bronchi

- lung parenchyma

- oesophagus

- pleura

- Trachea (Pfitzmann 2020).

Visible swelling of the corresponding area of skin. When the skin is pressed, the typical crackling, so-called crepitatio or crepitation, is noticed (Bork 2008).

When the hands are placed on the chest, subcutaneous crackling indicates skin emphysema that is not (yet) visible (Rieger 2004).

In addition to the physical examination with visible swelling of the subcutis, a typical crackling sound can be triggered by applying pressure to the swollen area (Rieger 2004).

Da Costa Medeiros described another diagnostic method in 2018. Here, the stethoscope is gently placed on the swelling and the sound of small bursting bubbles with a sound emission energy between 750 and 1,200 Hz can be auscultated.

In the presence of skin emphysema in the thoracic region, a pneumothorax or tension pneumothorax should always be excluded (Durst 1997).

X-ray

Radiologically, skin emphysema appears as an irregular, patchy brightening. Between muscle fibers, e.g. those of the pectoralis muscle, the typical image of a fan is created (Durst 1997).

Extensive emphysema can lead to:

- Hypercapnia

- Pneumopericardium (Siewert 2006)

- Pneumomediastinum

- Tension pneumothorax (Larsen 2009)

Skin emphysema in itself does not always require treatment (Durst 1997).

Skin emphysema after dental procedures, for example, usually resolves spontaneously within a few days. However, due to the increased risk of infection, antibiotics should be administered (Bork 2008) with cefalosporins such as cefuroxime axetil 500 mg 2x / d i.v. for 14 days (Radtke 2006).

Activities that may be associated with fluctuating pressure exposures, such as swimming, air travel, sauna, diving, etc. should be avoided at all costs until regression (Radtke 2006).

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