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due to intermittent pain caused by impaction&#46; She had no history of systemic disease&#46; The dentist used compressed air to dry out the operative field during the procedure&#46; The wound was closed with sutures and the patient tolerated the procedure well&#46; Twelve hours later&#44; the patient complained of epigastric pain and was brought to our emergency room&#46; When she got to our hospital her vital signs were&#58; temperature&#44; 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; heart rate&#44; 78<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#44; respiratory rate&#44; 24&#47;min and blood pressure 114&#47;70<span class="elsevierStyleHsp" style=""></span>mmHg&#46; She did not present with any abdominal tenderness&#46; The peritoneal signs were also negative&#46; She only stated she had a dull pain in the epigastric region&#46; After observation for 2<span class="elsevierStyleHsp" style=""></span>h&#44; the patient&#39;s initial epigastric pain resolved but she started to complain of retrosternal pain and mild dyspnea&#46; The oxygenation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; was 99&#37; with an oxygen cannula at 2<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; She presented with an elevated body temperature &#40;38&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; tachypnea &#40;30&#47;min&#41; and tachycardia &#40;heart rate&#58; 110<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Saturation was maintained at approximately 99&#37; with the oxygen cannula at 2<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; Physical examination showed palpable subcutaneous emphysema involving the submandibular region&#44; anterior and lateral aspect of the neck&#44; as well as the bilateral supraclavicular regions&#46; There were minor inflammatory signs but there was no local dental infection&#46; Chest radiograph showed pneumomediastinum and subcutaneous emphysema in the neck region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A computed tomography scan was performed that showed&#58; emphysema extending from the mandibular region to the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#44; as well as the presence of pneumopericardium and left side pneumothorax &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41; The laboratory tests showed slightly elevated white counts 12400&#47;&#956;L without shift-to-left&#46; The band form was 4&#37; and the segmented form was 80&#37; of total leukocytes&#46; C-reactive protein was 7&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; After treatment with a second-generation cephalosporin administered intravenously along with oxygen and oral non-steroid anti-inflammatory drug&#44; the fever subsided within 24<span class="elsevierStyleHsp" style=""></span>h after admission and the symptoms resolved&#46; The patient was discharged 4 days later&#46; After discharge&#44; the patient took oral first-generation cephalosporin for an additional five days&#46; She had a complete clinical and radiological recovery without recurrence of disease &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">The simultaneous occurrence of emphysema&#44; pneumothorax&#44; pneumopericardium and pneumomediastinum&#44; after dental treatment&#44; is rarely reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Pousios et al&#46; reported a 29-year-old man who had undergone the extraction of his right lower wisdom teeth&#46; He presented similar symptoms of dyspnea and substernal pain as in our case&#46; Air dissection was found to extend from the mandibular region to the mediastinum&#46; She was treated with a 5-day oral anti-inflammatory agent regimen&#46; Air dissection to the level of the pneumopericardium and pneumothorax is even more rare&#44; and very serious&#46; In dental surgical procedures&#44; the soft tissues are opened in order to extract the impacted teeth&#46; When the wound is created&#44; potential surgical dissection planes appear&#46; For ease of observation and operation&#44; continuous compressed air of high flow may be required&#44; but the air has the potential to penetrate into the soft tissues and cause damage&#46; The potential dissection planes include wounds of the gingiva&#44; hypopharynx&#44; cervical fascia&#44; pre-tracheal and para-tracheal fascia of the anterior mediastinum&#46; When the pressure of emphysema has increased to a certain extent&#44; the mediastinal pleura may rupture and then the air will accumulate in the pleural space&#44; namely a pneumothorax&#46; Because the operated oral cavity is not sterile&#44; such a procedure carries a risk of deep neck infection&#44; mediastinal infection and even pleural space infection&#46; The prolonged use of compressed air may result in a pneumothorax&#44; as in this patient&#39;s clinical case&#46; Tension pneumothorax&#44; sepsis&#44; and air embolism may be lethal if not appropriately treated&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Another potential cause is the use of hydrogen peroxide&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Because of the existence of such potentially fatal complications&#44; careful attention should be given to patients presenting with chest pain after recent tooth extraction&#46; If fever develops&#44; mediastinal infection ought to be considered in the differential diagnosis and should be treated promptly&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pulmonary complications&#44; although rare&#44; may arise in patients after dental procedures&#46; Physicians should be aware of the possibility of this happening&#46; Careful observation of the clinical course and appropriate conservative treatment usually solves the problem&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Pneumothorax, pneumomediastinum and pneumopericardium complications arising from a case of wisdom tooth extraction
Pneumotórax, pneumomediastino e pneumopericárdio como complicações decorrentes de um processo de extração do dente do siso
C.-H. Chena,b,c,
Corresponding author
musclenet2003@yahoo.com.tw

Corresponding author.
, H. Changb, H.-C. Liua,b, T.-T. Hunga,b,c, W.-C. Huanga
a Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
b Graduate Institute of Mechanical and Electrical Engineering, National Taipei University of Technology, Taipei City, Taiwan
c Mackay Medicine, Nursing and Management College, Taipei City, Taiwan
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tooth extraction is a very common dental procedure&#46; During this procedure&#44; compressed dry air is frequently applied to clear the operative field&#46; On rare occasions&#44; compressed air may lead to dissection of soft tissues proximal to the extraction site&#46; Even more rarely&#44; the air may penetrate into the mediastinum and pleural space&#46; Here we report such a rare case&#44; with severe air dissection caused by the use of compressed air during wisdom tooth extraction&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 25-year-old woman underwent surgical extraction of one of her left upper wisdom teeth &#40;third molar&#41; due to intermittent pain caused by impaction&#46; She had no history of systemic disease&#46; The dentist used compressed air to dry out the operative field during the procedure&#46; The wound was closed with sutures and the patient tolerated the procedure well&#46; Twelve hours later&#44; the patient complained of epigastric pain and was brought to our emergency room&#46; When she got to our hospital her vital signs were&#58; temperature&#44; 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; heart rate&#44; 78<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#44; respiratory rate&#44; 24&#47;min and blood pressure 114&#47;70<span class="elsevierStyleHsp" style=""></span>mmHg&#46; She did not present with any abdominal tenderness&#46; The peritoneal signs were also negative&#46; She only stated she had a dull pain in the epigastric region&#46; After observation for 2<span class="elsevierStyleHsp" style=""></span>h&#44; the patient&#39;s initial epigastric pain resolved but she started to complain of retrosternal pain and mild dyspnea&#46; The oxygenation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; was 99&#37; with an oxygen cannula at 2<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; She presented with an elevated body temperature &#40;38&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; tachypnea &#40;30&#47;min&#41; and tachycardia &#40;heart rate&#58; 110<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Saturation was maintained at approximately 99&#37; with the oxygen cannula at 2<span class="elsevierStyleHsp" style=""></span>L&#47;min&#46; Physical examination showed palpable subcutaneous emphysema involving the submandibular region&#44; anterior and lateral aspect of the neck&#44; as well as the bilateral supraclavicular regions&#46; There were minor inflammatory signs but there was no local dental infection&#46; Chest radiograph showed pneumomediastinum and subcutaneous emphysema in the neck region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A computed tomography scan was performed that showed&#58; emphysema extending from the mandibular region to the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#44; as well as the presence of pneumopericardium and left side pneumothorax &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41; The laboratory tests showed slightly elevated white counts 12400&#47;&#956;L without shift-to-left&#46; The band form was 4&#37; and the segmented form was 80&#37; of total leukocytes&#46; C-reactive protein was 7&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; After treatment with a second-generation cephalosporin administered intravenously along with oxygen and oral non-steroid anti-inflammatory drug&#44; the fever subsided within 24<span class="elsevierStyleHsp" style=""></span>h after admission and the symptoms resolved&#46; The patient was discharged 4 days later&#46; After discharge&#44; the patient took oral first-generation cephalosporin for an additional five days&#46; She had a complete clinical and radiological recovery without recurrence of disease &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">The simultaneous occurrence of emphysema&#44; pneumothorax&#44; pneumopericardium and pneumomediastinum&#44; after dental treatment&#44; is rarely reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Pousios et al&#46; reported a 29-year-old man who had undergone the extraction of his right lower wisdom teeth&#46; He presented similar symptoms of dyspnea and substernal pain as in our case&#46; Air dissection was found to extend from the mandibular region to the mediastinum&#46; She was treated with a 5-day oral anti-inflammatory agent regimen&#46; Air dissection to the level of the pneumopericardium and pneumothorax is even more rare&#44; and very serious&#46; In dental surgical procedures&#44; the soft tissues are opened in order to extract the impacted teeth&#46; When the wound is created&#44; potential surgical dissection planes appear&#46; For ease of observation and operation&#44; continuous compressed air of high flow may be required&#44; but the air has the potential to penetrate into the soft tissues and cause damage&#46; The potential dissection planes include wounds of the gingiva&#44; hypopharynx&#44; cervical fascia&#44; pre-tracheal and para-tracheal fascia of the anterior mediastinum&#46; When the pressure of emphysema has increased to a certain extent&#44; the mediastinal pleura may rupture and then the air will accumulate in the pleural space&#44; namely a pneumothorax&#46; Because the operated oral cavity is not sterile&#44; such a procedure carries a risk of deep neck infection&#44; mediastinal infection and even pleural space infection&#46; The prolonged use of compressed air may result in a pneumothorax&#44; as in this patient&#39;s clinical case&#46; Tension pneumothorax&#44; sepsis&#44; and air embolism may be lethal if not appropriately treated&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Another potential cause is the use of hydrogen peroxide&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Because of the existence of such potentially fatal complications&#44; careful attention should be given to patients presenting with chest pain after recent tooth extraction&#46; If fever develops&#44; mediastinal infection ought to be considered in the differential diagnosis and should be treated promptly&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pulmonary complications&#44; although rare&#44; may arise in patients after dental procedures&#46; Physicians should be aware of the possibility of this happening&#46; Careful observation of the clinical course and appropriate conservative treatment usually solves the problem&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 25-year-old woman underwent surgical tooth extraction&#46; Several hours after the procedure&#44; the woman complained of severe retrosternal pain and mild dyspnea&#46; Subsequent imaging revealed subcutaneous emphysema from the mandibular region extending to the mediastinum and left side pneumothorax&#44; as well as pneumopericardium&#46; After treatment with antibiotics and analgesics&#44; the patient recovered without any complications&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher de 25 anos foi submetida a uma extra&#231;&#227;o dent&#225;ria&#46; V&#225;rias horas ap&#243;s o procedimento&#44; a mulher queixou-se de dor retroesternal aguda e dispneia ligeira&#46; Imagiologia posterior revelou enfisema subcut&#226;neo da regi&#227;o mandibular estendendo-se ao mediastino e pneumot&#243;rax &#224; esquerda&#44; bem como pneumoperic&#225;rdio&#46; Ap&#243;s o tratamento com antibi&#243;ticos e analg&#233;sicos&#44; a paciente recuperou sem quaisquer complica&#231;&#245;es&#46;</p>"
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Original language: English
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