Soft tissue cervicofacial emphysema after dental treatment -: Report of 2 cases with emphasis on the differential diagnosis of angioedema

Background: The development of soft tissue cervicofacial emphysema after dental treatment is a rare complication, with few descriptions in the dermatologic literature. It is usually restricted to only moderate local swelling. However, spread of larger amounts of air into deeper spaces may sometimes cause serious complications, including airway compromise due to accumulation of air in the retropharyngeal space, pneumomediastinum, and pneumopericardium. Fatal air embolism and soft tissue infections through dissemination of oral flora microorganisms along the emphysematous tracts have also been described. Therefore, early recognition is important, but the unfamiliarity of dermatologists with this condition often causes diagnostic problems. Important differential diagnoses include angioedema, soft tissue infections, and hematoma. Observations: We describe 2 patients with different severity of the emphysema and airway compromise, representing the wide spectrum of its clinical expression. Our first case was remarkable, because the emphysema was massive and extended far into deep spaces, including the orbita, mediastinum, and pleural cavity. The present case is only the third report of pneumothorax associated with dental treatment published to date. The patient's condition was initially misdiagnosed and treated. as angioedema. Conclusions: Dermatologists should be aware that soft tissue emphysema can cause acute swelling of the cervicofacial region after dental procedures. Angioedema is, an important differential diagnosis, because it may be caused by the use of nonsteroidal anti-inflammatory drugs or local anesthetics, which are often administered during dental treatments.