Question Isolated subcutaneous emphysema?

[SeaMarie]

TL;DR: Is it possible to have subcutaneous emphysema after diving without any other form of lung barotrauma?

_________



Hi!

I had an accident during a recent dive trip in Cozumel and I am desperate to know if I can ever dive safely again.



- Day 1 of the trip: After our first dive (60mins, max depth 18m), I scratched my forehead and happened to palpate subcutaneous emphysema (I am 100% sure it was that, I work in an ER). It was also present on my neck. I don't recall palpating my chest. I felt completely fine otherwise, so I decided to go for the second dive and everything went well. I still had the emphysema after the second dive but it went away in about 30 minutes. I don't recall anything that could have happened during the first dive to explain this (ie. Fast ascent, breath-holding).



- Day 2: no diving



- Day 3: I did 4 dives that day. I had emphysema after the first dive. By the end of the 4th dive, it was present on my face, neck, upper chest and both arms, up to the hands. Again, no other symptoms at that moment and it went away in about 60 minutes. It was only when I was lying in my bed in the evening that I started to feel some mild, non pleuretic, retrosternal chest pain radiating to my back, but it seemed pretty non specific to me (it could have felt like muscle pain).



- Day 4: As I had to fly home the next day, I finally decided to get checked up. I got a thoracic CT (15 hours after the last dive), which came back normal. I was asymptomatic at that time. After getting discharged from the hospital that same day, I went for a swim in the sea and a small amount of emphysema came back on my neck.



Both the Mexican dive doctor and the one I saw back home found this very strange, especially as the CT came back completely normal. I am not known for any lung disease either. To me, it seems a bit unlikely that a pneumomediastinum or pneumothorax would have caused the emphysema because, to my knowledge, these findings do not resolve as fast on imagery. Therefore, I am wondering if anyone has experienced or seen a similar case? Can subcutaneous emphysema be an entity on its own? Would it be a contraindication to diving?



Thank you!!

 

[Capt Jim Wyatt]

@Duke Dive Medicine

 

[Duke Dive Medicine]

TL;DR: Is it possible to have subcutaneous emphysema after diving without any other form of lung barotrauma?

_________



Hi!

I had an accident during a recent dive trip in Cozumel and I am desperate to know if I can ever dive safely again.



- Day 1 of the trip: After our first dive (60mins, max depth 18m), I scratched my forehead and happened to palpate subcutaneous emphysema (I am 100% sure it was that, I work in an ER). It was also present on my neck. I don't recall palpating my chest. I felt completely fine otherwise, so I decided to go for the second dive and everything went well. I still had the emphysema after the second dive but it went away in about 30 minutes. I don't recall anything that could have happened during the first dive to explain this (ie. Fast ascent, breath-holding).



- Day 2: no diving



- Day 3: I did 4 dives that day. I had emphysema after the first dive. By the end of the 4th dive, it was present on my face, neck, upper chest and both arms, up to the hands. Again, no other symptoms at that moment and it went away in about 60 minutes. It was only when I was lying in my bed in the evening that I started to feel some mild, non pleuretic, retrosternal chest pain radiating to my back, but it seemed pretty non specific to me (it could have felt like muscle pain).



- Day 4: As I had to fly home the next day, I finally decided to get checked up. I got a thoracic CT (15 hours after the last dive), which came back normal. I was asymptomatic at that time. After getting discharged from the hospital that same day, I went for a swim in the sea and a small amount of emphysema came back on my neck.



Both the Mexican dive doctor and the one I saw back home found this very strange, especially as the CT came back completely normal. I am not known for any lung disease either. To me, it seems a bit unlikely that a pneumomediastinum or pneumothorax would have caused the emphysema because, to my knowledge, these findings do not resolve as fast on imagery. Therefore, I am wondering if anyone has experienced or seen a similar case? Can subcutaneous emphysema be an entity on its own? Would it be a contraindication to diving?



Thank you!!

Hi @SeaMarie ,

Subcutaneous emphysema from diving would have most likely arisen from some kind of pulmonary barotrauma. How experienced a diver are you? What were the diving conditions like? Depth? Sea conditions/waves? Do you recall holding your breath at any point in the dive?

Small pulmonary blebs can be difficult to detect on CT. If they gave you a CD of the images, you might consider getting a second opinion on them and/or obtaining additional imaging.

I strongly recommend that you not dive until the cause of this can be determined and you can be evaluated by a physician trained and experienced in examining divers. Where exactly in Canada are you?

Best regards,
DDM

 

[Imla]

As an anecdote. I had exactly what you describe. Subq emphysema, krepitous airbubbles in the skin on my thighs and upper torso after I sat down i a very hot hottub after a day of diving in very cold water. Not the smartest thing. Lets just say that water of life was involved... It disappeared after a cold shower. I put it down to "localised heating with gas expansion in fatty sub q tissues due to rapid change in temperature".
Nothing in the profiles other than temperature were noteworthy.

 

[scubadada]

Hi @SeaMarie

I would suggest also discussing your case with DAN

 

[SeaMarie]

Hi @SeaMarie ,

Subcutaneous emphysema from diving would have most likely arisen from some kind of pulmonary barotrauma. How experienced a diver are you? What were the diving conditions like? Depth? Sea conditions/waves? Do you recall holding your breath at any point in the dive?

Small pulmonary blebs can be difficult to detect on CT. If they gave you a CD of the images, you might consider getting a second opinion on them and/or obtaining additional imaging.

I strongly recommend that you not dive until the cause of this can be determined and you can be evaluated by a physician trained and experienced in examining divers. Where exactly in Canada are you?

Best regards,
DDM

Hello @Duke Dive Medicine

Thank you for your reply! I am AOW certified with 41 dives and decent technique. Honestly, nothing really special happened during that first dive. I do remember sighing underwater/taking a very deep breath in at some point and feeling like there was a lot of air in my lungs but aside from that, nothing. No breath-holding, no fast ascent. All dives in Cozumel were drift dives with moderate current and max depths between 10-28 meters (although most were less than 15m). There were only small waves.

I happen to have a friend who is a radiologist and I asked him to take a look at the CD. He also said it was normal.

The physician I saw back home (Quebec) was also a dive medecine doctor. She asked for a consultation with a pneumologist and I am also waiting for a PFT. Like you said, she mentioned that blebs can be hard to see on scans and suggested the idea of an expiratory CT but preferred to wait for the opinion of the pneumologist first (as to not expose me to possibly unnecessary radiation). I will follow through with the PFT and consultation but, frankly, I am wondering if this is ultimately going to change anything. I don't have asthma symptoms in my day to day life. I am also a bit skeptical about what could be done if I indeed did have tiny blebs.


To be honest, I am heartbroken by the idea of having to stop diving forever. I know that this would be the safest and easiest thing to do. However, although I'm not a diving veteran, scuba does take a lot of place in my life.

Thank you for you time!

P.s. Out of curiosity, because of the external pressure, can diving make subcutaneous emphysema more prone to spreading instead of accumulating? I did not look that noticeably swollen after diving even though I had SubQ emphysema in my face/neck/arms.

 

[Duke Dive Medicine]

Hello @Duke Dive Medicine

Thank you for your reply! I am AOW certified with 41 dives and decent technique. Honestly, nothing really special happened during that first dive. I do remember sighing underwater/taking a very deep breath in at some point and feeling like there was a lot of air in my lungs but aside from that, nothing. No breath-holding, no fast ascent. All dives in Cozumel were drift dives with moderate current and max depths between 10-28 meters (although most were less than 15m). There were only small waves.

I happen to have a friend who is a radiologist and I asked him to take a look at the CD. He also said it was normal.

The physician I saw back home (Quebec) was also a dive medecine doctor. She asked for a consultation with a pneumologist and I am also waiting for a PFT. Like you said, she mentioned that blebs can be hard to see on scans and suggested the idea of an expiratory CT but preferred to wait for the opinion of the pneumologist first (as to not expose me to possibly unnecessary radiation). I will follow through with the PFT and consultation but, frankly, I am wondering if this is ultimately going to change anything. I don't have asthma symptoms in my day to day life. I am also a bit skeptical about what could be done if I indeed did have tiny blebs.


To be honest, I am heartbroken by the idea of having to stop diving forever. I know that this would be the safest and easiest thing to do. However, although I'm not a diving veteran, scuba does take a lot of place in my life.

Thank you for you time!

P.s. Out of curiosity, because of the external pressure, can diving make subcutaneous emphysema more prone to spreading instead of accumulating? I did not look that noticeably swollen after diving even though I had SubQ emphysema in my face/neck/arms.

Re the pressure of diving and its influence on subcutaneous emphysema, good question. The difference between the subq emphysema that you've seen in the ED and an event that occurs while diving is the reduction in ambient pressure on ascent, which will cause any pockets of subcutaneous air to expand. How and where it spreads is going to depend on the pressure in the air pocket as it works against the elasticity of the dermis and the strength of the bond between the dermis and the underlying tissue.

It sounds like you have a good way forward as far as medical evaluation. Provided you have a firm diagnosis of subq emphysema, a big question is whether a precipitating event can be identified. You didn't report a panic ascent or any type of deliberate breathholding so if there is one, it's likely subtle, e.g. transient glottal closure as a wave passes over in shallow water or while hanging on to a boat ladder that's moving up and down in the water column. If you and your medical team can't pinpoint one, then unfortunately diving would likely be contraindicated.

Best regards,
DDM

 

[SeaMarie]

Re the pressure of diving and its influence on subcutaneous emphysema, good question. The difference between the subq emphysema that you've seen in the ED and an event that occurs while diving is the reduction in ambient pressure on ascent, which will cause any pockets of subcutaneous air to expand. How and where it spreads is going to depend on the pressure in the air pocket as it works against the elasticity of the dermis and the strength of the bond between the dermis and the underlying tissue.

It sounds like you have a good way forward as far as medical evaluation. Provided you have a firm diagnosis of subq emphysema, a big question is whether a precipitating event can be identified. You didn't report a panic ascent or any type of deliberate breathholding so if there is one, it's likely subtle, e.g. transient glottal closure as a wave passes over in shallow water or while hanging on to a boat ladder that's moving up and down in the water column. If you and your medical team can't pinpoint one, then unfortunately diving would likely be contraindicated.

Best regards,
DDM

Alright! Thank you very much for your time and help!

Marie