Author:
Editor(s):
Updated:
ULY CLINIC
ULY CLINIC
26 Mei 2025, 19:39:32
Subcutaneous crepitation
Definition and clinical presentation
Subcutaneous crepitation is a clinical finding where gas accumulates in the subcutaneous tissues, producing a crackling or popping sound during palpation, akin to touching bubble wrap. It is often detected in regions such as the neck, chest wall, eyelids, or extremities. While usually painless, it is commonly associated with painful and critical underlying disorders. The overlying skin may show swelling, edema, or visible signs of inflammation depending on the etiology.
Pathophysiology and mechanisms
Air or gas enters subcutaneous tissues via:
Traumatic or spontaneous rupture of air-filled structures (e.g., lungs, bronchi, esophagus).
Surgical or diagnostic instrumentation, including bronchoscopy, endoscopy, or thoracic surgery.
Infectious causes, especially gas-forming organisms in necrotizing infections such as gas gangrene.
Emergency diagnostic and therapeutic considerations
1. Initial rapid assessment
Due to its association with potentially fatal conditions, any patient presenting with subcutaneous crepitus warrants:
Airway assessment: Monitor for dyspnea, use of accessory muscles, nasal flaring, and cyanosis.
Breathing and circulation support: Oxygen supplementation, IV access, and cardiac monitoring.
Hamman’s sign: Auscultated crunching sound over the precordium synchronized with the heartbeat, indicating pneumomediastinum.
2. Delineation and Monitoring
Mark borders of palpable crepitus to monitor progression.
Reassess frequently to detect spread or new complications.
Medical Causes of Subcutaneous Crepitation
Below is a table of medical causes of subcutaneous crepitation, including associated symptoms and special considerations:
Condition | Crepitation Site | Associated Symptoms | Special Considerations |
Gas gangrene | Over infected wound/muscle | Severe pain, swelling, bullae, necrotic tissue, foul-smelling discharge, tachycardia, cyanosis, fever, lassitude | Surgical emergency; caused by anaerobic Clostridium species; needs debridement + antibiotics |
Orbital fracture | Eyelid/orbit | Subcutaneous air in periorbital tissue, ecchymosis, diplopia, facial edema, hyphema, restricted extraocular movement | Often due to trauma; check for globe rupture and optic nerve function |
Pneumothorax | Upper chest and neck | Dyspnea, asymmetrical chest expansion, ↓ breath sounds, hyperresonance, tachycardia, anxiety, cyanosis, accessory muscle use | Subcutaneous air suggests a tension or traumatic pneumothorax |
Esophageal rupture | Neck, chest wall, supraclavicular fossa | Severe pain (neck, chest, scapula), soft tissue swelling, dysphagia, fever, dyspnea, mediastinal emphysema, Hamman’s sign | Life-threatening; spontaneous (Boerhaave’s) or traumatic; requires surgical repair |
Tracheobronchial rupture | Neck and anterior chest wall | Abrupt crepitus, severe dyspnea, hemoptysis, cyanosis, hypotension, anxiety, mediastinal shift, Hamman’s sign | Often traumatic or iatrogenic; rapid respiratory compromise |
Diagnostic procedures (e.g., bronchoscopy) | Neck/chest/abdomen (depending on site) | Cough, pain, dyspnea, crepitus near procedural site | Suspect perforation if subcutaneous emphysema follows a recent endoscopic procedure |
Mechanical ventilation (barotrauma) | Chest wall/neck | Increased airway pressure, subcutaneous air, respiratory distress | Risk ↑ with high PEEP; watch for pneumothorax or mediastinal emphysema |
Thoracic surgery | Near incision site | Localized swelling, crepitus near surgical site | Often benign but monitor for expanding pneumothorax or wound dehiscence |
Special populations and situational considerations
Pediatrics
Ingestion of caustic substances can perforate the esophagus, resulting in cervical emphysema.
Surgical context
Be cautious in postoperative thoracic or neck patients presenting with swelling or crepitus.
Clinical management strategies
Immediate interventions
Airway: Be prepared for intubation or tracheostomy if airway is compromised.
Supplemental oxygen: Facilitates reabsorption of nitrogen-rich subcutaneous air.
Chest tube insertion: If pneumothorax is confirmed.
Broad-spectrum antibiotics and surgical debridement: If anaerobic infection is suspected.
Monitoring
Vital signs: Continuous monitoring, especially respiratory rate and oxygen saturation.
Imaging: Chest X-ray, CT scan to localize air and assess organ integrity.
Patient education and prognosis
Most cases resolve as gas is reabsorbed over time if the source is controlled.
Counsel patients on warning signs: worsening dyspnea, chest pain, or systemic symptoms.
For traumatic or infectious etiologies, hospitalization and aggressive management are often warranted.
References
Rezende-Neto JB, Hoffmann J, Al Mahroos M, et al. Occult pneumomediastinum in blunt chest trauma: Clinical significance. Injury. 2010;41(1):40–43.
Zhao DY, Zhang GL. Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection. Zhongguo Zhen Jiu. 2009;29(3):239–242.
Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema: pathophysiology, diagnosis, and management. Arch Intern Med. 1984;144(7):1447–53.
Maunder RJ, Pierson DJ. Management of subcutaneous emphysema. Chest. 1983;84(4):703–4.
Kaneki T, Kubo K, Kawashima A, Sekiguchi M, Honda T, Fukushima M, et al. Subcutaneous and mediastinal emphysema following spontaneous pneumomediastinum. Intern Med. 2000;39(5):380–2.
FitzMaurice BG, Brough MD, Rowlands RG. Subcutaneous emphysema. Anaesthesia. 1996;51(11):1070–3.
Macklin MT, Macklin CC. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions. Medicine (Baltimore). 1944;23(4):281–358.
Maunder RJ. Severe subcutaneous emphysema. Chest. 1983;84(6):782–3.
Williams JL, Babb RM, Shively EH. Subcutaneous emphysema and pneumomediastinum after laparoscopic cholecystectomy. Surg Endosc. 1995;9(1):94–7.
Martinez-Balzano CD, Dorfman DM, Rosen CL. Subcutaneous emphysema following endobronchial ultrasound–guided transbronchial needle aspiration. J Bronchology Interv Pulmonol. 2014;21(4):347–9.
Kanaya A, Tachibana H, Nakagomi T, Kanai M. Extensive subcutaneous emphysema after dental treatment: A case report and review of the literature. BMC Oral Health. 2020;20(1):63.
Abolnik IZ, Lossos IS, Breuer R. Spontaneous pneumomediastinum: A report of 25 cases. Chest. 1991;100(1):93–5.