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Subcutaneous emphysema

Subcutaneous emphysema, strictly speaking, refers to air in the subcutaneous tissues. But the term is generally used to describe any soft tissue emphysema of the body wall or limbs, since the air often dissects into the deeper soft tissue and musculature along fascial planes.

Clinical presentation

Clinically it is felt as crepitus and, if extensive, may cause soft tissue swelling and discomfort. Even when severe subcutaneous emphysema is typically benign, although complications such as airway compromise, respiratory failure, pacemaker malfunction and tension phenomena have been described.

Pathology

Causes of subcutaneous emphysema can be divided into :

  • gas introduced externally
    • penetrating trauma
    • post-surgical
    • post-percutaneous intervention
      • e.g. pleural drain insertion
  • gas produced de novo

Radiographic appearance

Plain film

If affecting the anterior chest wall, subcutaneous emphysema can outline the pectoralis major muscle, giving rise to the ginkgo leaf sign 2.

CT chest

Subcutaneous emphysema is readily visible on CT scans, with pockets of air seen as extremely dark low (air) attenuation areas in the subcutaneous space.

Treatment and prognosis

Treatment is directed at the underlying cause, while the subcutaneous air is absorbed by the body over time. Symptomatic management should also be provided.

However in rare instances management may involve release of the air by surgical division of the soft tissues or insertion of catheters.

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