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• W1970166314 abstract "A six year-old child presented for excision of a thyroglossal cyst. On the day of the operation, the parents also asked for the child to be circumcised. Preoperative examination was unremarkable and an intravenous induction was performed. Atracurium was administered and the trachea intubated. An atraumatic caudal for pain relief was performed using levobupivacaine 0.5 mg.kg−1. The two operations were uneventful. Sistrunk's procedure was performed which involves cutting out the cyst and its track, and a section of the hyoid bone was excised. The wound was infiltrated with local anaesthetic. In the recovery room, the child achieved consciousness, had no pain and was sent back to the ward. One of us (ORD) visited the child post operatively. The child was gagging and keening. Paracetamol and ibuprofen were administered. Although he was a ‘day case’, it was elected to keep him in over night. At 20 h the child had an energetic cough and within a minute or so, his face and neck swelled up with crepitating tissue ‘oedema’. The child was kept in for a further three days until the swelling subsided. The airway was not compromised at any stage. Walter Sistrunk described the procedure for excision of the cyst and the track in 1920 [1]. He reported good results, with an incidence of complications less than 10%, mostly recurrence and infection. Series have been reported since then [2]. However, reviews of the procedure do not note how often air emphysema occurs in the postoperative period. Air emphysema of the face and neck is a pathognomic sign that there is a breach in the pharyngeal mucosa, and that consequent to this, air has escaped into the neck. This is a sign that anaesthetists do not often see and therefore diagnose, and frequently assume that the air must come from a breach of the trachea, but this is not always the case. One of the authors, who made the immediate diagnosis from this history, had been previously caught out by a delayed diagnosis of air emphysema in the face and neck of a child. That child was subjected to laparotomy and it was only later realised that the air in the neck had been due to a pharyngeal breach caused by an object being rammed into the child's mouth. This was obviously a case of suspected child abuse needing referral to the authorities. In that instance the diagnosis was delayed for at least 12 h whilst the child was in hospital, and this raised the possibility that the defence lawyers might plead that the injury had occurred after the child was admitted to hospital. In this case, the air emphysema was probably caused by a pharyngeal breach resulting from the energetic coughing. The mucosa around the portion of the excised hyoid bone would have lacked its original cartilage support and gave away. Once a breach has occurred, very little pressure is required to fill the neck tissues with air. ENT surgeons are well aware of this possibility but anaesthetists usually concentrate on causes below the larynx. The child was treated conservatively and the only morbidity was a delayed discharge. This case report illustrates how a demonstration of the primary pathology (air emphysema) and knowledge of its aetiology (a breach of pharyngeal mucosa) can lead to a speedy diagnosis and minimal morbidity." @default.
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• W1970166314 date "2004-01-16" @default.
• W1970166314 modified "2023-10-14" @default.
• W1970166314 title "Air emphysema in the neck after excision of a thyroglossal cyst" @default.
• W1970166314 cites W1990921073 @default.
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• W1970166314 doi "https://doi.org/10.1111/j.1365-2044.2003.03639.x" @default.
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