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Subcutaneous Emphysema of the Neck With Pneumomediastinum

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 30s presented to an outside emergency department with left-sided otalgia and periauricular swelling. He was discharged after being prescribed oral antibiotics but continued to have worsening symptoms and returned to the outside facility, where a noncontrasted computed tomographic (CT) scan of the neck and chest showed significant subcutaneous emphysema of the neck and mediastinum (Figure, A and B). He was subsequently transferred to our facility for additional treatment.

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D. Pneumoparotid

Pneumoparotid is characterized by retrograde movement of air through the parotid duct, or Stensen duct, into proximal structures of the parotid gland owing to increased intraoral pressures. Simultaneous parotid inflammation or infection by oral bacteria produces pneumoparotitis. Dissection of air through the parotid capsule can produce subcutaneous emphysema of the head and neck.1 Given its rarity, descriptions of pneumoparotitis and its treatments are limited to case reports and series, which include patients with unilateral or bilateral pneumoparotid from behavioral and iatrogenic causes.2 It occurs in patients who habitually expire against a closed or resisted oral aperture, such as wind instrumentalists and glass blowers.1,3 Multiple cases have been documented in children with psychiatric disorders.4 It has also been described from use of compressed air during dental procedures and positive pressure associated with anesthesia.2,5

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Article Information

Corresponding Author: Paige Egan Bundrick, MD, Department of Otolaryngology–Head & Neck Surgery, Louisiana State University Shreveport, 1501 Kings Hwy 9-203, Shreveport, LA 71103 (pegan@lsuhsc.edu).

Published Online: January 23, 2020. doi:10.1001/jamaoto.2019.4456

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Calcaterra  TC, Lowe  J.  Pneumoparotiditis. An unusual case of parotid gland swelling.  Arch Otolaryngol. 1973;97(6):468-469. doi:10.1001/archotol.1973.00780010482008PubMedGoogle ScholarCrossref
2.
McGreevy  AE, O’Kane  AM, McCaul  D, Basha  SI.  Pneumoparotitis: a case report.  Head Neck. 2013;35(2):E55-E59. doi:10.1002/hed.21873PubMedGoogle ScholarCrossref
3.
Greisen  O.  Pneumatocele glandulae parotis.  J Laryngol Otol. 1968;82(5):477-480. doi:10.1017/S0022215100068997PubMedGoogle ScholarCrossref
4.
Goguen  LA, April  MM, Karmody  CS, Carter  BL.  Self-induced pneumoparotitis.  Arch Otolaryngol Head Neck Surg. 1995;121(12):1426-1429. doi:10.1001/archotol.1995.01890120082017PubMedGoogle ScholarCrossref
5.
Alcalde  RE, Ueyama  Y, Lim  DJ, Matsumura  T.  Pneumoparotid: report of a case.  J Oral Maxillofac Surg. 1998;56(5):676-680. doi:10.1016/S0278-2391(98)90473-6PubMedGoogle ScholarCrossref
6.
Brodie  HA, Chole  RA.  Recurrent pneumosialadenitis: a case presentation and new surgical intervention.  Otolaryngol Head Neck Surg. 1988;98(4):350-353. doi:10.1177/019459988809800416PubMedGoogle ScholarCrossref
7.
Han  S, Isaacson  G.  Recurrent pneumoparotid: cause and treatment.  Otolaryngol Head Neck Surg. 2004;131(5):758-761. doi:10.1016/j.otohns.2004.04.035PubMedGoogle ScholarCrossref
8.
Gudlaugsson  O, Geirsson  AJ, Benediktsdóttir  K.  Pneumoparotitis: a new diagnostic technique and a case report.  Ann Otol Rhinol Laryngol. 1998;107(4):356-358. doi:10.1177/000348949810700416PubMedGoogle ScholarCrossref
9.
Konstantinidis  I, Chatziavramidis  A, Constantinidis  J.  Conservative management of bilateral pneumoparotitis with sialendoscopy and steroid irrigation.  BMJ Case Rep. 2014;2014:bcr2013201429. doi:10.1136/bcr-2013-201429PubMedGoogle Scholar
10.
Wilkie  TF, Brody  GS.  The surgical treatment of drooling. A ten-year review.  Plast Reconstr Surg. 1977;59(6):791-797. doi:10.1097/00006534-197706000-00001PubMedGoogle ScholarCrossref
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