Article info


Aslanidis Th.
Pertsas E.
Thoma G.


The Greek E-Journal of Perioperative Medicine 2021;20(c): 57-61




POSTED: 09/27/21 10:00 PM
ARCHIVED AS: 2021, 2021c, Case Reports

DOI: The Greek E-Journal of Perioperative Medicine 2021;20(c): 57-61

Authors: Thoma G.1, Pertsas E. 2, Aslanidis Th. 3*

1MD, Anesthesiology-Critical Care.
2MD, Cardiology-Critical Care.
3MD, PhD, Anesthesiology-Critical Care -Prehospital emergency medicine.

Intensive Care Unit, Saint Paul General Hospital, Thessaloniki, Greece

*Correspondence: Doridos str 4, PC 54633, Thessaloniki, Greece. E-mail: Tel.: +306972477166.



Subcutaneous emphysema (SE) refers to air in the subcutaneous tissues. Diagnosis is usually clinical, yet radiological confirmation is also useful. We present a case report of subcutaneous emphysema in a male patient with COVID-19 with presence of ginko leaf sign in radiological evaluation.



Subcutaneous emphysema (SE) refers to air in the subcutaneous tissues. Clinical manifestation is generally benign, yet in several cases it can provoke serious complications such as airway compromise, respiratory failure, pacemaker malfunction and tension phenomena.

Treatment is usually aiming at the underlined cause, while the air is gradually absorbed from interstitial tissues. However, in extensive cases, surgical intervention may also needed1. In the present article we present a case report of subcutaneous emphysema in patient with COVID-19 with presence of ginko leaf sign.

Case report

A 60-year-old man was transferred to our ICU, after presented with acute respiratory failure due to COVID-19, in another hospital (quick COVID-19 severity index-qCSI:12); and intubated soon after, in the emergency department. On admission a chest X-ray (CXR) was performed to confirm the position of endotracheal tube with findings correspondant to COVID lung involvement (Figure 1).

Figure 1. First CXR at ICU admission.

Yet, 28 hours post intubation clinical examination revealed signs of SE (Aghajanzadeh Grade IV), yet with slowly deterioration on respirartory monitoring parameters. Two consequent emergency CXRs revealed air in subcutaneous tissues around the neck and axilla with radiolucent striations around the individual fibres of bilateral pectoralis major muscles (Gingko leaf sign) (Figure 2).


Figure 2. Two CXRs taken 3 hours apart with signs of SE: Ginko leaf sign (sketch of the leaf and pectoralis muscle major on the right) and air in the mediastinum.


Though initially treated conservativately, due to steadily aggravating respiratory parameters, two chest drainage tubes were positioned in each side (Figure 3). Subcutaneous emphysema decreased over the next 3 days and the chest tubes were removed. Unfortunately, the patient passed away after 14 days because of complications (inhospital XDR Klebsiella pneumoniae, MDR Acinetobacter baumanni and Aspergillus fumigatus lung infection) during his ICU stay.

Figure 3. CXR with chest drainage tubes in situ.




SE etiology include surgical, traumatic, infectious conditions or even non underlying cause (spontaneous); with an incidence reported anywhere between 0.43-2.34%2. Male sex and age over 50 seem to be more often suffering from SE. Mechanisms for SE development include1:1) Injury to the parietal pleura that allows for the passage of air into the pleural and subcutaneous tissues 2) Air from the alveolus spreading into the endovascular sheath and lung hilum into the endothoracic fascia 3) The air in the mediastinum spreading into the cervical viscera and other connected tissue planes. 4) Air originating from external sources and 5) Gas generation locally by infections, specifically, necrotizing infections. Grading scores of the extend of SE have been validated in some studies, yet they remain underused in clinical practice2.

Diagnosis is clinical by palpating crepitus in the involved area. CXR shows air in the soft tissues and air around the pectoralis major create radiolucent striations outlining the individual fibre and gives the appearance of the venous system of Ginkgo leaf known as Ginkgo leaf sign3.

The majority cases are nonfatal and self-limited; yet in surgical intervention may also be necessary when there are compression symptoms1. In our patient, we believe that subcutaneous was secondary to tracheal injury following endotracheal intubation, a condition that is rare (0.005%). Bronchoscopic and computer tomography may provide valuable information in management of such cases. Due to SE extend (into mediastinum), a more “aggressive” strategy was followed.



Tracheal injury is a rare complication of endotracheal intubation and timely intervention can prevent morbidity and mortality. This chest radiograph shows the classical appearance of ‘Ginkgo leaf’ sign.

All cases of subcutaneous emphysema do not require active intervention; yet when needed, it should not be delayed.


Addittional materials:



Not applicable.

Authors’ contributions:

TG, EP: primary case management, TA: literature review and manuscript preparation from input of all authors. All authors read and approved the fnal manuscript.


Not applicable.

Availability of supporting data:

Not applicable.

Ethical approval and consent to participate:

No IRB approval required.

Patients Consent for publication:

Not applicable.

Competing interests:

The authors declare that they have no competing interests.

Received: May 2021, Accepted: May 2021, Published: September 2021


  1. Aslanidis T, Kontos A. Surgical treatment of subcutaneous emphysema. In which cases? Journal of Surgery and Emergency Medicine 2017. Vol.2.No 1:12
  2. Aghajanzadeh M, Dehnadi A, Ebrahimi H, et al. Classification and Management of Subcutaneous Emphysema: a 10-Year Experience. Indian J Surg. 2015;77(Suppl 2):673-67
  3. Abu-Omar Y, Catarino PA. Progressive subcutaneous emphysema and respiratory arrest. J R Soc Med. 2002 ;95(2):90-9
  4. Kumar H M, Mishra K, Jain A, et al. Ginko leaf sign and subcutaneous emphysema. BMJ Case Rep 2018;11:e227770. doi:10.1136/bcr-2018-227770.
  5. Lim H, Kim JH, Kim D, et al. Tracheal rupture after endotracheal intubation – a report of three cases. Korean J Anesthesiol2012; 62:277.
  6. Ovári A, Just T, Dommerich S, et al. Conservative management of post-intubation tracheal tears-report of three cases. J Thorac Dis2014;6: E85–91

Publisher’s Note

The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.


Citation: Thoma G, Pertsas E, Aslanidis Th. Ginko leaf sign and subcutaneous emphysema in a patient with COVID 19. Greek e j Perioper Med. 2021;20(c):57-61.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://

Αναβάθμιση του Impact Factor

RSS Feed
RDF Feed
Creative Commons License