Thoracocervicofacial Emphysema after Heimlich's Maneuvre

We report an extremely rare example of a thoracocervicofacial subcutaneous emphysema after Heimlich maneuver case.


Introduction
In 1974, Henry Heimlich described his life saving manoeuvre of abdominal infradiaphragmatic pressure to dislodge aspirated food from upper airways. The manoeuver of Heimlich consists in creating an increased intrathoracic pressure by means of an abrupt epigastric compression directed upwards [1], forcing expiry of the residual trapped intrapulmonary air followed by an expulsion of the foreign body in the airway. This forced air expiration, sometimes against a closed glottis, can be associated with complications which can be multiplied by the actual foreign body impaction in the upper aerodigestive tract. Here we report a case of subcutaneous thoracocervicofacial emphysema after Heimlich's maneuver.

Clinical Case
A 45-year-old Caucasian woman, mentally disabled, living in an institution of special care, presented with an acute onset chocking with respiratory distress during her meal. The care-taker nurse had noticed that she had eaten a large piece of chicken meat. Instantaneously, the nurse performed Heimlich's maneuver on three separate occasions. Immediately after the maneuver, the acute respiratory distress partially resolved, though the patient developed subcutaneous emphysema extending from the thorax to the face closing the eyelids completely. The blood oxygen saturation was above adequate. A transnasal fibreoptic laryngoscopy showed salivary stasis in both piriform sinuses. There was no laryngeal edema and vocal cord mobility was conserved. An urgent cervicothoracic CT scan ( Figure 1) done in the following hour revealed a three cm long foreign body of bone density located at the esophageal opening. In addition, massive subcutaneous emphysema was seen, cranially from the fat pad of Bichat extending posteriorly to the retropharyngeal space, the occipital region descending caudally to the axilla, and the mediastinum (Figures 2(a), 2(b), and 3). There the lung parenchyma was normal and there was no pleural effusion. A rigid pharyngoesophagoscopy was done 6 hours later extracting a large piece of bony chicken meat which was impacted in the right piriform sinus. On repeated endoscopy a 3 mm tear was seen at the apex of the right piriform sinus extending until the cricopharynx. Because the size of the tear was small we decided against an endoscopic repair of the tear only inserting a nasogastric feeding tube under endoscopic control. The patient was covered with amoxyclavulanic acid 1.2 g three times a day.
Twenty-four hours later, the patient redeveloped a progressive respiratory distress with increasing inflammatory parameters. The patient was febrile and had tachycardia (HR > 110/min). A new cervicothoracic CT scan was performed. It revealed a regression of the subcutaneous emphysema and the pneumomediastinum but showed evidence of bilateral pleural effusion and atelectasis. Bilateral intercostal drains were inserted in emergency. A new pharyngoesophagoscopy showed pus in the right piriform sinus. A right exploratory cervicotomy was performed to evacuate the abscess and showed no evidence of residual foreign body. The site was rinsed with dilute hydrogen peroxide and betadene R and closed over 2 easy-flow drains. The wound was rinsed with dilute betadine solution 2 times a day for the next 3 days. Antibiotherapy (amoxicillin-clavulanate) was continued for 2 Case Reports in Otolaryngology   10 days. The thoracic tubes were pulled out at day 5. Over the next few days the inflammatory parameters settled and the general condition improved. The cervical drains were removed on the sixth day. A cervicothoracic CT scan performed on day 9 showed a complete resolution of the cervical pneumomediastinum, the pleural effusion, and the subcutaneous emphysema. A barium study done at 2 weeks was normal and the patient was restarted on feeds.

Discussion
Heimlich's maneuver is used commonly in case of foreign body blockage in the superior aerodigestive tract but has been associated with many complications reported in the medical literature.
Pharyngoesophageal perforations can be caused by sharp foreign body impactions, external trauma, caustic injuries, and iatrogenically induced endoscopic interventions. The impaction of pharyngeal or oesophageal foreign body is responsible for a perforation in 2% of the cases [9,10]. To the best of our knowledge, Heimlich's maneuver performed for a sharp foreign body impaction leading to a secondary hypopharyngeal perforation has not yet been described in the literature. Following a foreign body impaction, subcutaneous emphysema on clinical examination and mediastinal emphysema on radiological imaging should evoke suspicion of a pharyngoesophageal tear. The emphysema can be exaggerated by raised intrathoracic and abdominal pressures during Heimlich's maneuver which is commonly advocated to relieve foreign body impactions in the upper aerodigestive tract. This is exactly what happened in our patient in whom Heimlich's maneuver unfortunately complicated a foreign body impaction causing a more serious pneumomediastinum. In our patient the pharyngeal perforation led to a fistula and subsequently mediastinitis. Prompt surgical drainage of the abscess, intercostal drains, and intravenous broad-spectrum antibiotics were given to treat the patient.
Subcutaneous emphysema usually regresses by itself over 3-10 days. Surgical exploration allows the release of emphysema, but it is important to drain this wound by an easyflow, Penrose, or corrugated rubber drains. A tight closure without a drain will not allow the release of the air trapped within the subcutaneous planes. Oral feeds are started only when there is evidence of complete pharyngeal fistula healing on a barium swallow study and the inflammatory parameters settle. In case of pharyngeal or esophageal perforation, the traditional treatment is surgery. Many writers described the medical treatment without serious complications [10][11][12]. For Skinner et al., the treatment of perforation in the piriform sinus must be based on the extension [13]. High pharyngeal fistulas can be closed by an endoscopic approach, whereas distal or esophageal fistulas need open approach and closure. In our case, medical treatment failed probably because of extensive subcutaneous emphysema. It would have been ideal if we had extracted the sharp foreign body endoscopically and explored the neck during the same time to evacuate the emphysema which could have avoided the mediastinal complications.