Cervicofacial emphysema (CE) is a rare but potentially serious condition that can arise iatrogenically from dental or surgical procedures. Dental handpieces with fore-exhaust can inject air into tissues at pressures at or greater than 30 psi. Since 1963, there have been approximately 100 case reports in the literature of iatrogenic CE from routine dental procedures. Prompt recognition and treatment are essential; however, many general practitioners may only be familiar with CE from their dental school curriculum. A case of unusually severe cervicofacial emphysema with concomitant pneumomediastinum is presented, along with a discussion and review of management principles for the general dentist. It is our hope that refamiliarization with this condition will give the general dentist an appreciation for and recognition of signs of CE, thereby being the first. link in a chain of successful treatment.

Pneumomediastinum (PM) is defined as the presence of free air in the mediastinal cavity. It is often regarded as a revealing sign of a more serious medical condition. PM is broken down into two categories, one, with an instigating event, referred to as secondary PM. The other is when free air is discovered in the mediastinal cavity without a clear etiology, referred to as spontaneous pneumomediastinum (SPM). Often misdiagnosed due to the vague nature of presenting symptoms, SPM must be part of the differential diagnosis of a chest pain patient to expedite discovery and if necessary, management. A MedLine/PubMED search was performed identifying all relevant articles with \"SPM\" in the title. Six case series were reviewed to determine what clinical scenario constitutes a possible case of SPM. Results showed that almost all patients with SPM exhibited some chest pain, but Hamman\'s crunch was present in only one-fifth of patients. Patients with certain pre-existing pulmonary diseases showed a greater propensity for the presence of free air in the mediastinal cavity. SPM must be diagnosed and managed promptly due to rare, but serious complications and any chest pain with an unknown etiology should contain SPM in the differential diagnosis.

A four-year experience with transtracheal aspiration was reviewed in order to determine those patients at risk for developing life-threatening complications. One hundred procedures were performed by at least 20 different physicians trained according to an established protocol. Complications were limited to minimal subcutaneous emphysema in 19 percent (10/52), pneumomediastinum in 3 percent (3/93), and gross but self-limited hemoptysis in 1 percent (one patient); occasional unifocal premature ventricular contractions were noted in one patient. We conclude that patients not at risk of developing life-threatening complications from transtracheal aspiration can be identified. They (1) are able to cooperate and have a clearly identifiable and normal cricothyroid membrane, (2) have the procedure performed only by well-trained or supervised physicians, (3) have an arterial oxygen pressure of at least 70 mm Hg with administration of supplemental oxygen, and (4) have a prothrombin activity of at least 65 percent of the control value or a normal bleeding time or a platelet count of at least 100,000/cu mm. To minimize subcutaneous emphysema or pneumomediastinum, no patient should have therapy with intermittent positive-pressure breathing or any other procedure that might induce coughing for the subsequent 24 hours.