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General Articles: Case Report

Subcutaneous Cervical and Facial Emphysema with the Use of the Bonfils Fiberscope and High-Flow Oxygen Insufflation

Hemmerling, Thomas M. MD, DEAA; Bracco, David MD

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doi: 10.1213/01.ane.0000287661.81400.cb
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Subcutaneous facial emphysema is a rare complication, mainly encountered after dental interventions1–3 using devices delivering compressed air. Several cases have been reported in which tracheal laceration, with or without air insufflation during anesthesia, led to subcutaneous emphysema of the face or neck.4,5

We present a case of subcutaneous facial emphysema during air insufflation when using the Bonfils retromolar intubation fiberscope (Fig. 1, Storz Company, Tuttlingen, Germany).

Figure 1.:
The Bonfils fiberscope with oxygen tube attached to its air port for concomitant oxygen delivery. In our hospital setting, we usually use a high oxygen flow to maximize oxygenation during apneic manipulation. For our model, an external light source is attached, the stylet is rigid and cannot be moved.


A 75-yr-old patient (ASA I, 78 kg) was scheduled for abdominal hysterectomy in a tertiary teaching hospital. Preoperative evaluation revealed normal mouth opening, Mallampati I view with no suspicion for difficult airway. For teaching purposes, it was decided to use the Bonfils intubation fiberscope. The device was prepared in routine fashion with a camera attached. The oxygen port was used to insufflate oxygen during the procedure at 10 L/min. A standard 7.5 mm Mallinckrodt endotracheal tube was put on the Bonfils with sufficient lubrification.

Upon arrival in the operating room, standard monitoring was started using a three-lead electrocardiography, noninvasive arterial blood pressure and pulse oximetry, showing a normal sinus rhythm of 80/min, saturation of 95% and a arterial blood pressure of 145/74 mm Hg. Anesthesia was induced using fentanyl 250 μg and propofol 125 mg, after which mask ventilation was initiated at 100% oxygen for 2 min. The insertion of the Bonfils was facilitated using rocuronium 50 mg.

The mouth was opened easily using a cross finger mouth grip and the Bonfils inserted into the pharynx with the oxygen flowing at 10 L/min. The Bonfils was gently advanced towards the epiglottis. No laryngoscope was used. About 15–20 s after insertion of the Bonfils, the patient’s whole face abruptly swelled, resembling a puffer fish, with extensive subcutaneous facial, orbital, and neck emphysema. The Bonfils fiberscope was immediately withdrawn and endotracheal intubation performed using a laryngoscope. The view was slightly impaired by the smaller mouth opening. Oxygen saturation remained at 100% throughout this maneuver which took no more than 90 s. Careful examination of the mouth and throat did not reveal any laceration or tissue damage.

Surgery and anesthesia proceeded uneventfully and the trachea was safely extubated immediately after the 90 min operation. The patient was then transferred to the postanesthesia care unit where a radiograph of the neck was ordered. This showed extensive subcutaneous emphysema as expected (Fig. 2).

Figure 2.:
(a) This anterior-posterior radiograph taken in the postanesthesia care unit, approximately 3 h after occurrence of the subcutaneous emphysema; note the widespread occurrence of air in the neck and face. (b) Lateral radiograph of the neck showing widespread air.

The patient left the postanesthesia care unit 3 h after surgery. The subcutaneous emphysema resolved spontaneously within 24 h after surgery and the further postoperative course was uneventful.


We present a case of sudden extensive subcutaneous facial, orbital, and neck emphysema during use of the Bonfils with oxygen insufflation at 10 L/min.

It is thought that the high oxygen flow of 10 L/min through the air port of the Bonfils, together with a small lesion of the mucosal tissue or teeth, was responsible for the sudden entry of air into the subcutaneous tissues. A small mucosal lesion could have been spontaneously present or caused by the introduction of the rigid Bonfils fiberscope. The oxygen flow of 10 L/min was used to maximize apneic oxygenation during fiberoptic maneuvering. We were surprised by the sudden onset of the emphysema. Instantaneous clinical recognition of the possible source of the emphysema led to abandoning the Bonfils maneuvering and immediate change to standard laryngoscopy and endotracheal intubation.

Few cases of subcutaneous facial, orbital, or cervical emphysema are reported in the literature. They can be caused by increased alveolar pressure and subsequent air rupture of the terminal alveoli6 by coughing during respiratory tract infection or by other inflammatory processes. In addition, one case report describes subcutaneous orbital emphysema as a result of forceful nose blowing with subsequent air entering the orbita via the lamina papyracea.7

However, the most frequent incidences of subcutaneous facial emphysema are described after dental procedures where devices are used that create high air pressures and thus may insufflate dental cavities through holes in the teeth.3 In our case, no obvious laceration or visible dental holes could be detected. However, we cannot exclude the possibility that of tiny lesions had been caused by insertion of the Bonfils fiberscope. We believe that the 10 L/min of oxygen flow created a sufficient enough pressure to cause microscopic laceration of the mucosa, with subsequent passage of a large quantity of air into the subcutaneous tissue of neck and face up to the lower portion of the orbit. Subcutaneous skin emphysema without any evident port of entry has been described. It is believed that minimal lesions of the mucosa can be entry ports8 as can previously undetected lesions of the teeth roots.1,9 In addition, high-flow air insufflation might cause gastric distension, thus increasing the risk of aspiration.10–12

The Bonfils can be a useful new tool for difficult intubation.13 In our case, using the device with high oxygen insufflation created subcutaneous emphysema. Had the emphysema not been rapidly identified, the patient could have been harmed from airway compromise. After this experience, we have chosen to use the Bonfils intubating fiberscope only with a reduced flow of oxygen (<6 L/min).


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