Cervicofacial Surgical Emphysema Following Tonsillectomy: A Rare Complication Linked to Mucosal Disruption and Air Tracking.

Tonsillectomy is one of the most frequently performed procedures in ear, nose and throat (ENT) surgery, commonly indicated for recurrent tonsillitis, recurrent peritonsillar abscess, obstructive sleep apnoea or suspected malignancy. While generally safe, it carries recognised risks including haemorrhage, infection, pain and orodental trauma. Surgical emphysema is a rare but clinically significant complication, with fewer than 30 cases reported and an estimated incidence below 0.02%. It is hypothesised to result from mucosal or muscular disruption of the pharyngeal wall during dissection, particularly with electrocautery or aggressive technique, exacerbated by postoperative factors such as coughing, vomiting or Valsalva manoeuvres. We present the case of a 25-year-old woman who underwent elective tonsillectomy for recurrent tonsillitis. The procedure was uneventful, but she re-presented within 24 h with left-sided jaw and neck pain. Examination revealed cervicofacial crepitus, and CT imaging confirmed surgical emphysema extending from the submandibular region to the superior mediastinum and anterior chest wall. She was admitted for observation and treated conservatively with intravenous antibiotics and analgesia. Her symptoms resolved within 3 days, and she was discharged without further intervention. This case highlights the importance of early recognition and appropriate management of post-tonsillectomy surgical emphysema. Although rare, its potential severity, particularly in patients with respiratory comorbidities, warrants inclusion in preoperative counselling. In line with the Montgomery ruling, clinicians should consider individual risk factors when discussing consent. Greater awareness of this complication may support timely diagnosis and reinforce the value of nuanced risk communication in ENT practice.