Surgical emphysema

[nataliemay]

I have extreme surgical emphysema and wondered if anyone might be able to tell me what to expect during recovery and whether there is anything I can do to speed recovery along. It occured on a 30 metre dive. I'd had a significant eye trauma 2 days earlier and a cat scan after the emphysema presented, showed a blow out fracture. I have one eye I cannot open due to the extent of the swelling (even after 36 hours) and emphysema in my scalp down my neck.I'm now also suffering back pain and wondering if that's related.

 

[headsqueeze]

Hi,

It sounds like you have 'subcutaneous emphysema' as a result of either the surgical repair or your orbital fracture, or you went diving after your fist fight and surfaced with an inability to open your eye. Dunno but you are really vague on your history so here goes...

If you went diving w/ a black eye...

Your inferior orbital plate was fractured, resulting in an abnormal opening into the upper ceiling of your maxillary sinus. Equalizing would have forced air through the fracture into the periorbital tissue and possibly into the neural tissue along the orbital nerve. Upon ascent this now trapped compressed periorbital air expanded in the tissue causing 'subcutaneous emphysema'. The severity of the subcutaneous emphysema extending into your neck is hard to say - you need a CT of the orbit (after surgery too) neck and chest (non-contrast) ASAP to ensure your subcutaneous emphysema of the skin (not a real problem right now) is not indicating mediastinal emphsema (a real big problem) or extending along the optic nerve (a real big problem).

Your DCS could have been prevented. I think you know that already.

 

[nataliemay]

Thanks for your comments and sorry I was vague...I whacked my eye on a dive cylinder during a launch through surf on Monday. I hit the first stage hard. I was returned to the beach and went to see a doctor. He stiched up the cut, gave me prescription for a combined ibuprofen/paracetemol medication for pain and swelling and told me I was fit to dive (perhaps because he knew it's what I wanted to hear). The next two days I took it relatively easy, equalising tentatively and staying above 6 metres. On the first day's diving my traumatised eye swelled shut. This happened as soon as I attempted to equalise at about 2 metres. I returned to see the doctor after the dive and he said mask squeeze had irritated the eye but it would come down again and I should keep taking the prescribed pills and icing it.

The eye was much less puffy next morning and I went ahead with my second shallow dive. I didn't equalise by blowing against a pinched nose this time given that had caused my eye to swell instantly last time, instead I just swallowed and wiggled my jaw about enough to ease ear pain although I did suffer a little bit of block at 6 metres and then reverse block returning to surface. I also made sure I regularly exhaled through my nose to avoid any mask squeeze! I kept this to a short dive, ending it at about 15 minutes. My eye did not end this dive any more swollen than it started so I thought I thought I was on mend.

A shallow dive was not an option the following day and I went ahead with the planned dive. We were in current and the water was very choppy so the group did a negative entry. I did likewise but as agreed with the dive leader I stopped my decent at 2 or 3 metres, grabbed his SMB line and did a very slow decent down that to join group in my own time, so I could take my time equalising with my sore eye. I lost sight in my left eye from swelling on the descent (at about 6-10 metres). This eye was puffy anyway from the trauma and it had swelled up like this before and receeded within 12 hours so I didn't think too much of it and continued to make my way down. I joined the group at 30 metres and then came up with the group to 22 metres. They descended again somewhat but I thought a sawtooth profile was the last thing I needed so I returned to the dive leaders line and hung there until the group was ready to ascend. The dive was just beyond the no decompression limits - I dive with a VR3 and had a 2 minute stop at 18 metres and a 1 minute stop at 6 metres. At 22 metres I had felt a bit disorientated but put this
mostly down to being one-eyed. At 6 metres I felt decidedly uncomfortable with jaw and neck ache. I took about 2 minutes to ascend from 6, taking my time because of a feeling of some reverse block and general uncomfortableness.

Yes, with hindsight I should not have tried diving and further, having lost an eye on way down I should have aborted, but hindsight is a wonderfull thing and in my defense I had sought medical advice which had told me I was dive fit. And I'm on holiday with some of the worlds best diving and am used to UK waters so temptation got the better of common sense!

After surfacing the seriousness of my problem became apparent as face was so swollen as to shock my dive group, my chest felt tight and I had stabbing pains in my throat when I swallowed that made my worry my throat may close up and I might struggle to breathe. Withion hours of the end of the dive I saw a doctor (not the same one , as I am now at a different dive site), who diagnosed surgical emphysema and sent my to hospital where I was given a cat scan. The letter that accompanies my scans states: "axial as well as coronal study of sinuses and facial bones performed pre contrast... Extensive surgical emphysema noted in frontal subcutaneous region, both orbitae as well as intra orbital air bilaterally, but more pronounced on left extending as far as left optic foramen. Also evident subcutaneously around mandible and skull base as well as upper neck. A left side blow out fracture is noted. The lamina papyracea are intact. Septum deviated with turbinate engorgement. There is small fluid level noted in right antrum but no right sided orbital or other fractures demonstrated. The mastoids are clear. No intracranial free air or haemorrages, midline or central"

But that's all medical jargon to me and the doctor who assessed my results said he'd never seen anything like it before and wasn't able to say a great deal about recovery timescales. I've been advised to see a doctor again before I fly home (supposedly) next week. I am on antibiotics (avelon) and 'Brufen' to reduce swelling. I'm just reaching out for anyone with experience of this kind of thing. I would like comment on whether I can expect to be fit to fly in a week (36 hours after my last dive on Thursday I went to bed with no noticeable reduction to the puffiness. I've woken this morning able to see out of left eye again but still with a face that makes kids stare and point).

At the hospital the doctor said I needed facial surgery for the fracture. Without surgery he reckoned I might sustain some eye damage (eye muscle getting damaged by fracture?). The GP on the other hand seemed suprised by this diagnosis and did not agree, so dont know if I need further medical treatment or not. Also I haven't had any guidance on when I will be dive fit again. My next booked dive trip is not until end of May - could I dive before this? Will I be safe to dive then?

Any thoughts welcome... One thing I note is that descents, rather than just ascents, caused me problems...

 

[TSandM]

I would definitely consult with an ENT or facial plastics person when you get home. Some blowout fractures need surgical repair to ensure that the eye remains in normal position and that the muscles that move the eye don't get trapped in the fracture. If the eye ends up too low, you'll have double vision, at least for a while.

It does sound as though the subcutaneous emphysema came through your fracture, since there was an abnormal communication between the air space of the maxillary sinus and your soft tissues. Subcu emphysema is, in and of itself, not dangerous. It's unsightly and uncomfortable, but the biggest issue with it is identifying where it came from, because it's a definite indication that something is very wrong somewhere. Lung overexpansion injury can cause it, which is a very dangerous cause in a diver (or anybody, for that matter). But it does not sound from your story as though you had any rapid or uncontrolled ascents or breath-holding, and the fracture is certainly a very reasonable cause.

Healing of fractures, in general, requires about six weeks, and I think if I were you, I'd want another scan showing solid healing before I dove again.

As far as flying goes, you will experience some expansion of the subcutaneous air pockets with ascent in the plane, so if there is still visible or palpable air in the tissues, it will get more obvious. Whether you will have absorbed all of the air in a week or not is hard to predict.

I'm sorry for this freak occurrence that has spoiled your trip!

 

[nataliemay]

Thanks. That's very helpful and reassuring. I will definitely follow your advice.

 

[doctormike]

Excellent replies from headsqueeze and TSandM... just thought that I would chime in here as an ENT doc...

Blowout fractures are pretty common, they classically result from a direct blow to the eye from a fist (or sometimes a baseball!). Fortunately, the eyeball itself is pretty tough, and the rapid increase in pressure is vented through the relatively weak bony walls of the eye socket. There are two types of blowout fractures: medial and inferior..

A medial blowout fracture is a break in the thin wall of bone between the nose (the sinuses, actually) and the eye (called the "Lamina Paprycea" or "paper plate"). Generally no treatment is needed for these, other than avoiding blowing your nose while it heals.

An inferior blowout fracture is a fracture of the floor of the orbit, the bone below the eye which is also the roof of the large maxillary sinus (in the cheek). These are the ones that may need to be fixed, since the eye may sag and give you double vision or noticeable assymmetry.

And, as has been noted above, the air in our air filled spaces (sinuses, ears, etc...) wants to get out on ascent after having been pressurized on descent. Normally the air in the maxillary sinus goes out the same way it came in: through the hole that connects the sinus to the nose and throat (the maxillary ostium). In your case, the air found another way out: through the fracture into the soft tissues of your eyes and face..

I would be surprised if the relatively minor pressure change with flying would push much more air into the soft tissues that you have done with diving, especially after a week or so, but it would be best to avoid blowing your nose or forceful valsalvas to clear your ears, if that is necessary. Unlike flying soon after diving, or after DCS, or with air around the brain (trapped intracranial air), having once had a blowout fracture shouldn't be an absolute contraindication to flying.

One last point - the follow up CT scan would be helpful in assessing the results of surgical repair, but it might not be reliable in determining whether or not your blowout fracture is really healed over. Bone in this region often heals by fibrous union - that is why a broken nose will look like a fresh fracture many years afterwards on an x-ray...

 

[nataliemay]

So I should defintely see an ENT specialist - not keen on risking double vision or a lopsided face! If surgery is advisable for my specific circumstance how quickly do I need it Since the trauma happened a week ago and its another week before Im home is there not a risk that Ill be too late for surgery to be effective?

 

[headsqueeze]

Now might be an appropriate time to shift attention away from your minor orbital blowout and DCS subcutaneous emphysema with deep orbital emphysema - 'surgical emphysema' - the radiologist more than likely has only seen similar residual air following ENT operations. Your neck and chest pain might be the more life threatening DCS of the two.

Your unique medical illness must not be managed by standard medical decisions. If so, then lack of insight and planning may lead to your preventable death. Do not deny your serious illness so as not to deny yourself a preventable complication and sucessful cure.

Your neck and back and chest pain have a reason. The cause is more than likely DCS somehow related to mediastinal structures. The anterior, middle and posterior mediastinum are 'tissue planes' that will allow extension of trapped air. Also, where there is air, there are bacteria and fungi. It is possible that your chest and neck pains are from a preexsisting disease such as coronary plaque.

You should strongly consider hyperbaric treatment, and at the least seek the advice AND EXAMINATION by a physician qualified to counsel and treat your DCS. Also, as with any orbital fracture, I generally prescribe prophylactic antibiotics. In your case, at risk for infection wherever trapped air resides, meningitis and descending mediastinitis.

You are in grave danger. I am sorry that you are facing this illness and hope you have a full recovery.

 

[nataliemay]

Thank you for your additional thoughts and comments. Is your DCS diagnosis based on my reporting of a backache or has something else I've mentioned about my circumstance led you to the conclusion I have DCS?

 

[headsqueeze]

Decompression sickness, or syndrome is a catch all phrase. It is also referred by other names such as aeroembolism, compressed air illness, diver's disease, dysbarism, and others. It is commonly known as 'the bends'.

Your 'trapped air' is inside tissue that has no scientific model to understand the effects. You ascended at a rate calculated for gas diffusion out of your vascular system and not directly from your maxilary sinus. Your ascent did not take into account an abnormal accumulation of compressed air in extraordinary tissue space. Your perioptic nerve tissue is 'bent', as is possibly your mediastinal tissue. Your CT did not include the entire neck and mediastinum, which would have been helpful to better understand the extent. The CT identified 'upper neck', but not in detail. This would technically qualify as the upper mediastinal tissue space which has a direct extension around your esophagus, trachea, phrenic nerve, lymphatic tissue, heart and central diaphragm. Your pain pattern indicates the need for further evaluation, and is consistent w/ aeroembolism within the mediastinal space - you feel it as chest and back pain.

The letter that accompanies my scans states: "axial as well as coronal study of sinuses and facial bones performed pre contrast... Extensive surgical emphysema noted in frontal subcutaneous region, both orbitae as well as intra orbital air bilaterally, but more pronounced on left extending as far as left optic foramen. Also evident subcutaneously around mandible and skull base as well as upper neck. A left side blow out fracture is noted. The lamina papyracea are intact. Septum deviated with turbinate engorgement. There is small fluid level noted in right antrum but no right sided orbital or other fractures demonstrated. The mastoids are clear. No intracranial free air or haemorrages, midline or central"