Extensive subcutaneous emphysema following lobectomy

We present a case report of extensive subcutaneous emphysema secondary to an elective left upper lobectomy. A 65-year-old gentleman was brought into a London teaching hospital's Accident and Emergency department following report of severe swelling. He was mistakenly treated by the paramedics as an allergic reaction and given hydrocortisone and salbutamol nebulisers with no effect. Upon arrival, the patient had widespread crepitus extending from his peri-orbital muscles down to mid-torso. A computer tomography scan revealed a pleuro-cutaneous fistula at the site of a recently sited chest drain, with extensive emphysema and a pneumothorax. A Seldinger chest drain was successfully inserted under blind technique following two attempts. This case highlights the risk of subcutaneous emphysema following thoracic surgery, the importance of correct diagnosis and the difficulties of left-sided intercostal drains in patients with subcutaneous emphysema.