When air find it’s way :  Subcutaneous emphysema  following Endoscopic Laser Cordectomy- A rare early post operative complication

When air find it’s way : Subcutaneous emphysema following Endoscopic Laser Cordectomy- A rare early post operative complication | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report When air find it’s way : Subcutaneous emphysema following Endoscopic Laser Cordectomy- A rare early post operative complication Sirajum Muneerah binti Badreen Siraj This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8497965/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Intraoral laser cordectomy is a well-established minimally invasive procedure for the management of early glottic pathology 3 . It is a safe and effective option as an organ preservation strategy in the treatment of early glottic carcinoma as it is associated with less morbidity and a high percentage of local control, both overall and specific to survival 11 . Postoperative complications are generally mild 7 . However, subcutaneous emphysema is a rare but potentially serious early postoperative complication that may lead to airway compromise such as massive pneumothorax and pneumomediastinum if not promptly recognized 15 . subcutaneous emphysema laser cordectomy post-operative complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Trans-oral laser cordectomy is a surgical option for early stage glottic carcinoma 3 , offering good oncological outcome, 5 years laryngeal preservation rate is 90% with good swallowing function 2 . It is a preferred method than radiotherapy with respect to overall survival and laryngeal preservation 1 , 4 . Common complications of laser cordectomy includes bleeding, laryngeal edema, granulation tissue formation, and aspiration 5 . Subcutaneous emphysema one of the rare complication following laser cordectomy 6 , 7 . We present a rare case of early post-operative subcutaneous emphysema after trans-oral laser cordectomy, discussing possible mechanisms and to highlight importance of early recognition, and management strategies. Case Presentation A 68 years old female, with underlying history of rectal adenocarcinoma, done Ultra low anterior resection (ULAR) in April 2024. Presented with persistent hoarseness for 3 months. Otherwise, she denied dysphagia, odynophagia, aspiration symptoms, neck swelling or constitutional symptoms. Upon examination, she was alert, not tachypneic, no stridor heard. GRBAS assessment shows predominance of roughness component, grade 2. Intra -oral examination was unremarkable. There was no palpable neck swelling or lymph nodes. Proceeded with Functional Nasopharyngolaryngoscopy (FNPLS) which shows normal supraglottic structures, mass over anterior two-third of right vocal cord. However, bilateral vocal cord was mobile, symmetrical and there was no phonation gap seen. Hypopharynx subsites were clear. Subsequently, she was planned for Examination under anesthesia, Laryngeal Microsurgery and biopsy. Biopsy result, HPE reported as well differentiated squamous cell carcinoma. CECT neck was done, noted right glottic carcinoma with involvement of anterior commissure, focal bulge measures 0.4 x 0.5cm. Subsequently, done Examination under anesthesia, Direct Laryngoscopy, Trans-oral laser cordectomy with frozen section. Intubated with MLT size 5, without difficulty. Intra-operatively procedure was uneventful. Noted irregular lesion involving whole length of right vocal fold, involving anterior commissure. Left anterior one-third vocal fold thickened. Left false cord appears normal. Subglottic clear. Frozen section was done, showed tissue biopsy from left middle one -third vocal fold and anterior commissure negative for malignancy. Type V Cordectomy was done. No mucosal perforation or cartilage exposure was noted. Post operatively, she was extubated safely and transferred to ward . Upon review 4 hours post surgery, she had mild hoarseness only, otherwise she was comfortable under room air, no shortness of breath, no chest pain, no interscapular pain, no aspiration symptoms, no obstructive symptoms. On examination, vital sign stable, noted palpable crepitus involving bilateral neck level I to VI. Intra oral examination is unremarkable. Neck and Chest X-Ray done confirmed, subcutaneous emphysema with pneumomediastinum without pneumothorax. The patient was treated conservatively. Bed propped up 30 degrees, closed airway observation, continuous vital sign monitoring, voice rest and restriction of activities that increases the intra-thoracic pressure such as straining or coughing. IV Augmentin, IV Dexamethasone and pantoprazole was started post operatively. Noted subcutaneous emphysema resolving over period of 5 days. She was discharged home well. She was scheduled for follow-up 1 week post-surgery. During clinic review, noted she is well, resolved subcutaneous emphysema. HPE reveals clear margin achieved post laser cordectomy. No adjuvant therapy required subsequently. Discussion Laryngeal squamous cell carcinoma (LSCC) is a common malignancy, representing 30%–50% of all neoplasms in the head and neck 11 . The management of early stage (Tis, T1, T2) laryngeal cancer (Supraglottic, Glottic, and Subglottic) has evolved over the last 40 years from the classic open surgical resection techniques to a less aggressive and more functional endoscopic approach 11 . Transoral Laser microsurgery was first proposed by Strong and Jako in 1972 8 .Subsequently, the application spread worldwide reporting, high rates of local control(90–94%), low rate of salvage total laryngectomy (0–4%) in selected cases if T1 vocal cord carcinoma 8 . In Transoral laser microsurgery, the resection is based on the tumor location and invasion. Surgeon removes the abnormal tissue with margins and preserves normal structures to ensure adequate functional outcomes 8 . European Laryngological Society (ELS) published a classification of the different cordectomies that are classified according to six types 9 . Transoral laser Microsurgery became the gold standard for surgical treatment of early vocal fold cancers through the two last decades as this approach was associated with many benefits in terms of oncological and functional outcome such as high disease-free survival, local, or regional control rates, and larynx preservation rate 8 . Even though it is established as effective option in managing early glottic carcinoma 2 , 3 , complications may occur. These includes bleeding being most common 7 , aspiration pneumonia, local infection with perichondritis seen in surgery with endolaryngeal exposure of thyroid cartilage 10 , subcutaneous emphysema 6 , 7 . In this report, we explored one of the rare major complication of transoral laser microsurgery, the subcutaneous emphysema 11 . Subcutaneous emphysema occurs when air escapes from the normal airway lumen (larynx, trachea, pharynx) into subcutaneous tissues, creating pockets of air in the neck and face 12 . It is generally regarded as a benign condition, however it can pose a significant amount of discomfort to the patient and in rarer cases it has been reported to cause high airway pressure, severe respiratory acidosis, pacemaker malfunction, airway compromise, mediastinal infection, which in could be life threatening 12 . In the context of transoral laser microsurgery, subcutaneous emphysema is thought to result from: Microscopic mucosal breaches at the resection site 12 . Positive pressure ventilation forcing air into paraglottic or subcutaneous spaces 13 , 15 Postoperative coughing/straining 13 . Iatrogenic trauma due to use of instruments, or traumatic intubation 14 . In our case, the development of subcutaneous emphysema is probably due to breach of inner perichondrium of the right thyroid cartilage. Even though the subcutaneous emphysema was extensive involving bilateral neck level I to VI, the patient recovered well with conservative management. Thus, emphasizing the importance of early recognition and management of this rare complication that can arise from trans-oral laser microsurgery . Conclusions Subcutaneous emphysema, although rare, may occur following transoral laser cordectomy due to mucosal microperforations, positive pressure ventilation or post operative coughing or straining. Awareness enables early diagnosis and safe management which may improves outcome of the surgery and quality of life. Declarations Compliance with ethical standards Funding information: Conflict of interest: All contributing authors declare that they have no conflict of interest. Ethical approval: Not required for case report. Informed consent: Patient consented for publication. Author Contribution SM - author of manuscrIPTKA - editorYXY - surgeonZZ - surgeon References Mo HL, Li J, Yang X, Zhang F, Xiong JW, Yang ZL et al (2017) Transoral laser microsurgery versus radiotherapy for T1 glottic carcinoma: a systematic review and meta-analysis. Lasers Med Sci [Internet] 32(2):461–467 Tomifuji M, Araki K, Shiotani A (2012) Transoral Surgery for Laryngeal Cancer. Koutou (THE LARYNX JAPAN) [Internet] del Mundo DAA, Morimoto K, Masuda K, Iwaki S, Furukawa T, Teshima M et al (2020) Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer. Auris Nasus Larynx 47(2):276–281 Vaculik MF, MacKay CA, Taylor SM, Trites JRB, Hart RD, Rigby MH (2019) Systematic review and meta-analysis of T1 glottic cancer outcomes comparing CO2 transoral laser microsurgery and radiotherapy. J Otolaryngol - Head Neck Surg. ;48(1) Bruzgielewicz A, Osuch-Wójcikiewicz E, Grzegorz J, Szwedowicz Paweł, Domeracka-Kołodziej A, Zawadzka R et al (2011) Powikłania leczenia wczesnego raka głośni za pomocą lasera CO2. Otolaryngol Pol 65(5):78–84 Hakim Tawil JA, Granados N, Santivañez JJ (2025) Cervical Cutaneous Emphysema after Laser Microsurgery for Treatment of Laryngeal Cancer: Case Report. 104(2suppl):46S48S Ear, nose, & throat journal [Internet] Vilaseca-González I, Bernal‐Sprekelsen M, José‐Luis Blanch‐Alejandro, Moragas‐Lluis M (2002) Complications in transoral CO 2 laser surgery for carcinoma of the larynx and hypopharynx. Head Neck 25(5):382–388 Hans S, Baudouin R, Circiu MP, Florent Couineau, Lisan Q, Crevier-Buchman L et al (2022) Laryngeal Cancer Surgery: History and Current Indications of Transoral Laser Microsurgery and Transoral Robotic Surgery. J Clin Med 11(19):5769–5769 Remacle M, Van Christophe H, Bradley P, Chevalier D, Djukic V et al (2007) Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies. Eur Arch Otorhinolaryngol 264(5):499–504 Reinoso F, Velasquez A, Fernandez J, Conde J, Hidalgo C, Chiesa Estomba C (2015) Complications in CO2 Laser Transoral Microsurgery for Larynx Carcinomas. Int Archives Otorhinolaryngol 20(02):151–155 Chiesa-Estomba CM, José González-García Ekhiñe, Larruscain, Calvo-Henriquez C, Mayo-Yáñez M (2019) Jon Alexander Sistiaga-Suarez. CO2 Transoral Laser Microsurgery in Benign, Premalignant and Malignant (Tis, T1, T2) Lesion of the Glottis. Literature Rev 6(3):77–77 Lodhia JV, Tenconi S (2021) Postoperative subcutaneous emphysema: prevention and treatment. Shanghai Chest 5:17–17 Chang YN, Lee JC, Chen JJ, Lin YS (2010) A Rare Complication After Microlaryngeal Surgery: Subcutaneous Emphysema and Pneumomediastinum. J Chin Med Association 73(5):268–270 Shimamoto Y, Sanuki M, Kurita S, Ueki M, Kuwahara Y (2022) A Novel Case Report of Iatrogenic Tracheal Rupture Caused by a Laser-Resistant Endotracheal Tube Under Transoral Laser Laryngeal and Nasopharyngeal Surgery. Am J Case Rep. ;23 Georgescu C, Margaritescu C, Osman I, Stoica M, Mitroi M, Surlin V (1990) Therapeutic management of massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum after anterior cordectomy for in situ vocal cord carcinoma - case report. Chirurgia (Bucharest, Romania: [Internet]. 2014;109(6):822–6 Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":355769,"visible":true,"origin":"","legend":"\u003cp\u003ePre-operative lesion, anterior two-third right vocal cord squamous cell carcinoma.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8497965/v1/d26e2965b00256de6eabc40d.jpeg"},{"id":100009265,"identity":"4a304bef-4983-465c-ba76-49b60659af7b","added_by":"auto","created_at":"2026-01-12 06:01:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":671164,"visible":true,"origin":"","legend":"\u003cp\u003eSubcutaneous emphysema developed early post op.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8497965/v1/45c2e15c9ccb58c2c9c5c754.jpeg"},{"id":100009268,"identity":"f8f99188-a325-49bb-94f6-6702f1db5e18","added_by":"auto","created_at":"2026-01-12 06:01:18","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":623832,"visible":true,"origin":"","legend":"\u003cp\u003eNeck and Chest X-Ray post operative – subcutaneous emphysema with pneumomediastinum\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8497965/v1/3744e26b854958a46492c3a1.jpeg"},{"id":100009264,"identity":"1ef6d308-85ee-4974-a814-995e4e9bd525","added_by":"auto","created_at":"2026-01-12 06:01:18","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":28193,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Discussion of section\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8497965/v1/c0465ad6656957438eadf773.jpeg"},{"id":100548843,"identity":"a9ce9614-1151-40c1-b92b-4f9a2959c625","added_by":"auto","created_at":"2026-01-19 08:21:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2075231,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8497965/v1/67a819ac-5c2a-4906-b8d1-10deda4c77f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"When air find it’s way : Subcutaneous emphysema following Endoscopic Laser Cordectomy- A rare early post operative complication","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTrans-oral laser cordectomy is a surgical option for early stage glottic carcinoma\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, offering good oncological outcome, 5 years laryngeal preservation rate is 90% with good swallowing function\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. It is a preferred method than radiotherapy with respect to overall survival and laryngeal preservation\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCommon complications of laser cordectomy includes bleeding, laryngeal edema, granulation tissue formation, and aspiration\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Subcutaneous emphysema one of the rare complication following laser cordectomy\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe present a rare case of early post-operative subcutaneous emphysema after trans-oral laser cordectomy, discussing possible mechanisms and to highlight importance of early recognition, and management strategies.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 68 years old female, with underlying history of rectal adenocarcinoma, done Ultra low anterior resection (ULAR) in April 2024. Presented with persistent hoarseness for 3 months. Otherwise, she denied dysphagia, odynophagia, aspiration symptoms, neck swelling or constitutional symptoms.\u003c/p\u003e \u003cp\u003eUpon examination, she was alert, not tachypneic, no stridor heard. GRBAS assessment shows predominance of roughness component, grade 2. Intra -oral examination was unremarkable. There was no palpable neck swelling or lymph nodes. Proceeded with Functional Nasopharyngolaryngoscopy (FNPLS) which shows normal supraglottic structures, mass over anterior two-third of right vocal cord. However, bilateral vocal cord was mobile, symmetrical and there was no phonation gap seen. Hypopharynx subsites were clear.\u003c/p\u003e \u003cp\u003eSubsequently, she was planned for Examination under anesthesia, Laryngeal Microsurgery and biopsy. Biopsy result, HPE reported as well differentiated squamous cell carcinoma.\u003c/p\u003e \u003cp\u003eCECT neck was done, noted right glottic carcinoma with involvement of anterior commissure, focal bulge measures 0.4 x 0.5cm.\u003c/p\u003e \u003cp\u003eSubsequently, done Examination under anesthesia, Direct Laryngoscopy, Trans-oral laser cordectomy with frozen section. Intubated with MLT size 5, without difficulty. Intra-operatively procedure was uneventful. Noted irregular lesion involving whole length of right vocal fold, involving anterior commissure. Left anterior one-third vocal fold thickened. Left false cord appears normal. Subglottic clear. Frozen section was done, showed tissue biopsy from left middle one -third vocal fold and anterior commissure negative for malignancy. Type V Cordectomy was done. No mucosal perforation or cartilage exposure was noted. Post operatively, she was extubated safely and transferred to ward .\u003c/p\u003e \u003cp\u003eUpon review 4 hours post surgery, she had mild hoarseness only, otherwise she was comfortable under room air, no shortness of breath, no chest pain, no interscapular pain, no aspiration symptoms, no obstructive symptoms. On examination, vital sign stable, noted palpable crepitus involving bilateral neck level I to VI. Intra oral examination is unremarkable.\u003c/p\u003e \u003cp\u003eNeck and Chest X-Ray done confirmed, subcutaneous emphysema with pneumomediastinum without pneumothorax.\u003c/p\u003e \u003cp\u003eThe patient was treated conservatively. Bed propped up 30 degrees, closed airway observation, continuous vital sign monitoring, voice rest and restriction of activities that increases the intra-thoracic pressure such as straining or coughing. IV Augmentin, IV Dexamethasone and pantoprazole was started post operatively. Noted subcutaneous emphysema resolving over period of 5 days. She was discharged home well.\u003c/p\u003e \u003cp\u003eShe was scheduled for follow-up 1 week post-surgery. During clinic review, noted she is well, resolved subcutaneous emphysema. HPE reveals clear margin achieved post laser cordectomy. No adjuvant therapy required subsequently.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eLaryngeal squamous cell carcinoma (LSCC) is a common malignancy, representing 30%\u0026ndash;50% of all neoplasms in the head and neck\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The management of early stage (Tis, T1, T2) laryngeal cancer (Supraglottic, Glottic, and Subglottic) has evolved over the last 40 years from the classic open surgical resection techniques to a less aggressive and more functional endoscopic approach\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTransoral Laser microsurgery was first proposed by Strong and Jako in 1972\u003csup\u003e8\u003c/sup\u003e.Subsequently, the application spread worldwide reporting, high rates of local control(90\u0026ndash;94%), low rate of salvage total laryngectomy (0\u0026ndash;4%) in selected cases if T1 vocal cord carcinoma\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn Transoral laser microsurgery, the resection is based on the tumor location and invasion. Surgeon removes the abnormal tissue with margins and preserves normal structures to ensure adequate functional outcomes\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. European Laryngological Society (ELS) published a classification of the different cordectomies that are classified according to six types\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTransoral laser Microsurgery became the gold standard for surgical treatment of early vocal fold cancers through the two last decades as this approach was associated with many benefits in terms of oncological and functional outcome such as high disease-free survival, local, or regional control rates, and larynx preservation rate\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEven though it is established as effective option in managing early glottic carcinoma\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, complications may occur. These includes bleeding being most common\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, aspiration pneumonia, local infection with perichondritis seen in surgery with endolaryngeal exposure of thyroid cartilage\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, subcutaneous emphysema\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this report, we explored one of the rare major complication of transoral laser microsurgery, the subcutaneous emphysema\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Subcutaneous emphysema occurs when air escapes from the normal airway lumen (larynx, trachea, pharynx) into subcutaneous tissues, creating pockets of air in the neck and face\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. It is generally regarded as a benign condition, however it can pose a significant amount of discomfort to the patient and in rarer cases it has been reported to cause high airway pressure, severe respiratory acidosis, pacemaker malfunction, airway compromise, mediastinal infection, which in could be life threatening\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the context of transoral laser microsurgery, subcutaneous emphysema is thought to result from:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMicroscopic mucosal breaches at the resection site\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePositive pressure ventilation forcing air into paraglottic or subcutaneous spaces\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePostoperative coughing/straining\u003csup\u003e13\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIatrogenic trauma due to use of instruments, or traumatic intubation \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIn our case, the development of subcutaneous emphysema is probably due to breach of inner perichondrium of the right thyroid cartilage.\u003c/p\u003e \u003cp\u003eEven though the subcutaneous emphysema was extensive involving bilateral neck level I to VI, the patient recovered well with conservative management. Thus, emphasizing the importance of early recognition and management of this rare complication that can arise from trans-oral laser microsurgery .\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSubcutaneous emphysema, although rare, may occur following transoral laser cordectomy due to mucosal microperforations, positive pressure ventilation or post operative coughing or straining. Awareness enables early diagnosis and safe management which may improves outcome of the surgery and quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with ethical standards\u003c/h2\u003e \u003cp\u003eFunding information:\u003c/p\u003e \u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eAll contributing authors declare that they have no conflict of interest.\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval:\u003c/strong\u003e \u003cp\u003e \u003cb\u003eNot required for case report.\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent:\u003c/strong\u003e \u003cp\u003e \u003cb\u003ePatient consented for publication.\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSM - author of manuscrIPTKA - editorYXY - surgeonZZ - surgeon\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMo HL, Li J, Yang X, Zhang F, Xiong JW, Yang ZL et al (2017) Transoral laser microsurgery versus radiotherapy for T1 glottic carcinoma: a systematic review and meta-analysis. Lasers Med Sci [Internet] 32(2):461\u0026ndash;467\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomifuji M, Araki K, Shiotani A (2012) Transoral Surgery for Laryngeal Cancer. Koutou (THE LARYNX JAPAN) [Internet]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003edel Mundo DAA, Morimoto K, Masuda K, Iwaki S, Furukawa T, Teshima M et al (2020) Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer. Auris Nasus Larynx 47(2):276\u0026ndash;281\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaculik MF, MacKay CA, Taylor SM, Trites JRB, Hart RD, Rigby MH (2019) Systematic review and meta-analysis of T1 glottic cancer outcomes comparing CO2 transoral laser microsurgery and radiotherapy. J Otolaryngol - Head Neck Surg. ;48(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruzgielewicz A, Osuch-W\u0026oacute;jcikiewicz E, Grzegorz J, Szwedowicz Paweł, Domeracka-Kołodziej A, Zawadzka R et al (2011) Powikłania leczenia wczesnego raka głośni za pomocą lasera CO2. Otolaryngol Pol 65(5):78\u0026ndash;84\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHakim Tawil JA, Granados N, Santiva\u0026ntilde;ez JJ (2025) Cervical Cutaneous Emphysema after Laser Microsurgery for Treatment of Laryngeal Cancer: Case Report. 104(2suppl):46S48S Ear, nose, \u0026amp; throat journal [Internet]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVilaseca-Gonz\u0026aacute;lez I, Bernal‐Sprekelsen M, Jos\u0026eacute;‐Luis Blanch‐Alejandro, Moragas‐Lluis M (2002) Complications in transoral CO\u003csub\u003e2\u003c/sub\u003e laser surgery for carcinoma of the larynx and hypopharynx. Head Neck 25(5):382\u0026ndash;388\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHans S, Baudouin R, Circiu MP, Florent Couineau, Lisan Q, Crevier-Buchman L et al (2022) Laryngeal Cancer Surgery: History and Current Indications of Transoral Laser Microsurgery and Transoral Robotic Surgery. J Clin Med 11(19):5769\u0026ndash;5769\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRemacle M, Van Christophe H, Bradley P, Chevalier D, Djukic V et al (2007) Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies. Eur Arch Otorhinolaryngol 264(5):499\u0026ndash;504\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReinoso F, Velasquez A, Fernandez J, Conde J, Hidalgo C, Chiesa Estomba C (2015) Complications in CO2 Laser Transoral Microsurgery for Larynx Carcinomas. Int Archives Otorhinolaryngol 20(02):151\u0026ndash;155\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiesa-Estomba CM, Jos\u0026eacute; Gonz\u0026aacute;lez-Garc\u0026iacute;a Ekhi\u0026ntilde;e, Larruscain, Calvo-Henriquez C, Mayo-Y\u0026aacute;\u0026ntilde;ez M (2019) Jon Alexander Sistiaga-Suarez. CO2 Transoral Laser Microsurgery in Benign, Premalignant and Malignant (Tis, T1, T2) Lesion of the Glottis. Literature Rev 6(3):77\u0026ndash;77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLodhia JV, Tenconi S (2021) Postoperative subcutaneous emphysema: prevention and treatment. Shanghai Chest 5:17\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang YN, Lee JC, Chen JJ, Lin YS (2010) A Rare Complication After Microlaryngeal Surgery: Subcutaneous Emphysema and Pneumomediastinum. J Chin Med Association 73(5):268\u0026ndash;270\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimamoto Y, Sanuki M, Kurita S, Ueki M, Kuwahara Y (2022) A Novel Case Report of Iatrogenic Tracheal Rupture Caused by a Laser-Resistant Endotracheal Tube Under Transoral Laser Laryngeal and Nasopharyngeal Surgery. Am J Case Rep. ;23\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgescu C, Margaritescu C, Osman I, Stoica M, Mitroi M, Surlin V (1990) Therapeutic management of massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum after anterior cordectomy for in situ vocal cord carcinoma - case report. Chirurgia (Bucharest, Romania: [Internet]. 2014;109(6):822\u0026ndash;6\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"subcutaneous emphysema, laser cordectomy, post-operative complications","lastPublishedDoi":"10.21203/rs.3.rs-8497965/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8497965/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntraoral laser cordectomy is a well-established minimally invasive procedure for the management of early glottic pathology\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. It is a safe and effective option as an organ preservation strategy in the treatment of early glottic carcinoma as it is associated with less morbidity and a high percentage of local control, both overall and specific to survival\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Postoperative complications are generally mild\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. However, subcutaneous emphysema is a rare but potentially serious early postoperative complication that may lead to airway compromise such as massive pneumothorax and pneumomediastinum if not promptly recognized\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e","manuscriptTitle":"When air find it’s way : Subcutaneous emphysema following Endoscopic Laser Cordectomy- A rare early post operative complication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:01:09","doi":"10.21203/rs.3.rs-8497965/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4947a6a6-99b5-46fc-8483-5aabb48d2634","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T02:24:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 06:01:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8497965","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8497965","identity":"rs-8497965","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}