Vomiting-Induced Pneumomediastinum and Subcutaneous Emphysema Does Not Always Indicate Boerhaave's Syndrome: Report of Six Cases

The unnecessary workups and admissions of adolescents and young adults with spontaneous pneumomediastinum

Spontaneous pneumomediastinum (SPM) is a rare condition in children and young adults that raises concern for esophageal perforation or extension of an air leak, resulting in admissions with multiple interventions performed. To assess our outcomes, and to evaluate our resource utilization, we reviewed our experience with SPM. We conducted a retrospective review of SPM cases in patients aged 5-25 years old occurring between 2011 and 2021 at a single academic tertiary care center. Clinical, demographic, and outcome variables were collected and analyzed, and cohorts were compared using Fischer's Exact Test and Welch's T Test. 166 SPM cases were identified-all of which were Emergency Department (ED) presentations. 84% of the cases were admitted. 70% had Computerized Tomography (CT) scans, with no defined criteria for imaging. Comparison of floor admissions with discharges from the ED showed no significant difference in presenting symptoms, demographics, or outcomes between the two groups. Recurrence was noted in 4 patients with a range of 5.9 months-4.9 years from the initial episode. In the largest SPM study in the pediatric and young adult population, we noted no significant difference in management or outcomes in admitted or ED discharge patients nor those with CT imaging. Our results suggest that a large number of SPM can be managed safely with discharge from the ED.

Utility of fluoroscopic oesophagography in the setting of spontaneous and blunt traumatic pneumomediastinum

AIM

To determine the incidence of positive fluoroscopic oesophagography in patients presenting with spontaneous or blunt traumatic pneumomediastinum.

MATERIALS AND METHODS

Retrospective chart review was performed on patients who underwent fluoroscopic oesophagography for spontaneous or blunt traumatic pneumomediastinum between 2001-2019. Patients were excluded for history of oesophageal surgery, penetrating trauma, oesophageal cancer, or tracheal/oesophageal instrumentation.

RESULTS

Two hundred and fifty-two patients met the inclusion criteria; 170 presented with spontaneous pneumomediastinum and 82 presented with blunt traumatic pneumomediastinum. Fluoroscopic oesophagography was positive in eight patients with spontaneous pneumomediastinum, for a positivity rate of 4.7% (8/170). There was one false-negative case in a patient who presented with spontaneous pneumomediastinum and was found to have a non-full-thickness oesophageal injury on endoscopy. Fluoroscopic oesophagography was negative in all patients with blunt traumatic pneumomediastinum (0/82). The sensitivity and specificity of fluoroscopic oesophagography were 88.9% (8/9) and 100% (243/243), respectively. Oesophageal injury was more common in patients with spontaneous pneumomediastinum and a pleural effusion (5/11, 45.4%) than in patients with spontaneous pneumomediastinum and no pleural effusion (4/159, 2.5%, p<0.001).

CONCLUSION

The present findings do not support routine oesophagography in patients with blunt traumatic pneumomediastinum. Conversely, a positivity rate of 4.7% in patients with spontaneous pneumomediastinum suggests oesophagography may be warranted in this population, particularly if an associated pleural effusion is present.

[Pneumomediastinum and vomiting: Which approach to diagnosis? A case report]

BACKGROUND

Spontaneous pneumomediastinum (SPM) is a rare and often unrecognized condition of which vomiting is one of the reported triggering factors. Differentiating SPM from Boerhaave's syndrome (pneumomediastinum secondary to esophageal breach) is the first step in management and prognosis.

OBSERVATION

A 27-year-old woman with systemic lupus erythematous presented to the emergency department with epigastralgia, incoercible vomiting and diarrhoea. Abdominal CT showed circumferential thickening of the duodenum and bilateral ureteritis. Chest sections showed pneumomediastinum extending to the cervical region. Therapeutic management was based on prophylactic antibiotic therapy and an absolute diet (fasting). A CT scan with upper gastrointestinal opacification was performed to prevent esophageal rupture and showed quasi-obstructive thickening of the antral mucosa. The diagnosis was lupus enteritis and pneumomediastinum was secondary to the vomiting efforts. The patient was placed on corticosteroids and a favorable outcome ensued.

CONCLUSION

Strenuous vomiting is one of the precipitating factors of SPM. Boerhaave's syndrome is the main differential diagnosis with a poor prognosis, unlike SPM, which has a good prognosis with conservative treatment.

OUP accepted manuscript

Vomiting-induced pneumomediastinum is often caused by oesophageal perforation or alveolar rupture due to increased pressure. A correct diagnosis is important because both diseases have different treatments and severities. We report the case of a 21-year-old man who presented with chest pain and fever after frequent vomiting and had elevated white blood cell counts on blood tests. There was extensive pneumomediastinum, and the lower oesophagus was swollen and thickened on chest computed tomography. An oesophagram was not possible due to severe nausea and vomiting. Accumulation of free air was found along the peripheral bronchi or the pulmonary vascular sheath in the left lower lobe, which was continuous with the mediastinum. Based on the presence of the Macklin effect, we diagnosed a pneumomediastinum with a high possibility of spontaneous pneumomediastinum. The Macklin effect is a finding that can likely distinguish oesophageal perforation from spontaneous pneumomediastinum.

Spontaneous Pneumorachis - A Case-Based Review

Pneumorachis is characterized by the presence of free air in the spinal canal. It is referred by different names in literature such as epidural emphysema, intraspinal air, intraspinal pneumoc(o)ele, spinal epidural and subarachnoid pneumatosis, spinal and epidural emphysema, aerorachia, pneumosaccus, air myelogram, etc. Pneumorachis can be broadly classified as traumatic, iatrogenic, or spontaneous. In this case-based review, we present a case of spontaneous pneumorachis secondary to asthma exacerbation. This is followed by a systematic review of all cases of spontaneous pneumorachis identified in PubMed. The aim of this review is to understand the pathophysiology, common causes and the management of spontaneous pneumorachis.

[Spontaneous pneumomediastinum: a rare benign diagnosis in young adults (a case report)]

Le pneumomédiastin spontané se définit par la présence d´air au niveau du médiastin survenant en dehors de tout contexte traumatique, iatrogène ou d´une maladie pulmonaire sous-jacente. C´est une affection rare, qui survient chez le jeune adulte et l´adolescent. Son principal risque est d´être confondu avec un tableau de fistule aéro-digestive, conduisant parfois à la réalisation d´investigations et de mesures thérapeutiques inutiles, voire délétères. Nous rapportons le cas d´un pneumomedisatin spontané survenu chez une femme jeune au décours d´un effort de vomissement.

Spontaneous pneumomediastinum secondary to hyperemesis gravidarum: A case report and principles of recognition and management

Pneumomediastinum is the presence of aberrant air in the mediastinum and is most commonly caused by oesophageal or alveolar rupture. Hyperemesis gravidarum is persistent nausea and vomiting before the 20th week of pregnancy and can increase intra-thoracic pressure, precipitating pneumomediastinum.

A 22-year-old patient presented with hyperemesis gravidarum in the 6th week of pregnancy. During her hospital admission, she developed chest pain, and imaging showed pneumomediastinum. Endoscopy excluded oesophageal perforation, a diagnosis of spontaneous pneumomediastinum was made, and her symptoms improved with conservative management.

This case demonstrates how oesophageal perforation and spontaneous mediastinum can present in similar fashion. Oesophageal perforation has high morbidity and mortality and it is vital to identify it early. It is therefore important that clinicians are aware of pneumomediastinum as a potential complication of hyperemesis gravidarum and exclude oesophageal perforation in these individuals.

•

Pneumomediastinum is a rare complication of Hyperemesis Gravidarum.

•

The first priority of management of pneumomediastinum in pregnancy is to rule out oesophageal rupture

•

Once oesophageal rupture has been excluded, management for spontaneous pneumomediastinum can commence.

•

Spontaneous pneumomediastinum can often be treated conservatively.

Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report

BACKGROUND

Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis.

AIM

Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported.

METHODS

Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper.

RESULTS-SYSTEMATIC-LITERATURE-REVIEW

Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space.

RESULTS-ILLUSTRATIVE-CASE-REPORT

Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days.

STUDY LIMITATIONS

Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population.

CONCLUSIONS

Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.

Vomiting-induced pneumomediastinum as a result of recurrent Boerhaave’s syndrome

Vomiting-induced pneumomediastinum can be a result of barotrauma causing alveolar rupture or Boerhaave’s syndrome. Although a rare cause of secondary pneumomediastinum, Boerhaave’s syndrome allows extravasation of air and fluid due to oesophageal perforation. We report a case of a 20-year-old female who presented with prolonged vomiting during a panic attack. Extensive surgical emphysema and pneumomediastinum were visualised radiologically. A source of oesophageal rupture was not visualised on cross-sectional computed tomography imaging following contrast ingestion. A complication of mediastinitis provided the evidence that this was a case of Boerhaave’s syndrome whereby microscopic perforation of the oesophagus led to secondary pneumomediastinum, rather than vomiting-induced spontaneous pneumomediastinum caused by barotrauma. Recurrent Boerhaave’s syndrome in this case is owed to the patient having previously experienced identical symptoms which spontaneously resolved.

Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum

Background There are no previous reports regarding the computed tomography (CT) findings of subpleural pulmonary interstitial emphysema (PIE) in patients with spontaneous pneumomediastinum. Purpose To evaluate CT findings of subpleural PIE that may indicate a direct site of terminal alveolar rupture. Material and Methods We retrospectively evaluated chest CT and the medical records of 34 patients with spontaneous pneumomediastinum. Subpleural PIE was defined as the presence of an interstitial air collection in the subpleural portion of the lungs excluding the bronchovascular bundle. Results Subpleural PIE on CT was identified in six of 34 patients (17.6%) with spontaneous pneumomediastinum. In four of these (66.7%), subpleural PIE was present in multiple lobes suggesting multiple simultaneous ruptures of terminal alveoli. The shape of subpleural PIE was elongated linear (4/6), branching and linear (1/6), and elliptical (1/6). Conclusion The presence of subpleural PIE on CT suggests an origin of pneumomediastinal air from alveolar rupture.

The Diagnosis and Management of Patient with Delayed Symptoms from a Tracheal Tear

Development of subcutaneous emphysema after gastrointestinal endoscopy with general anesthesia presents a diagnostic conundrum. We discuss the management of a patient who experienced significant vomiting followed by neck and facial swelling with crepitus and shortness of breath after the endoscopic retrograde cholangiopancreatography. The presence of respiratory distress usually suggests that head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. We discuss the prevention, differential diagnosis, and current management of tracheal tears including subcutaneous emphysema.

Spontaneous pneumomediastinum: Experience in 13 adult patients

BACKGROUND

Spontaneous pneumomediastinum is an uncommon disorder. There is a lack of information on spontaneous pneumomediastinum in India. We aimed to understand the clinical profile, hospital course, and long-term outcome of such patients.

METHODS

We retrospectively reviewed all patients (aged ≥15 years) diagnosed with spontaneous pneumomediastinum in the respiratory ward of a tertiary care hospital over a 7-year period from 2005.

RESULTS

Of the 3326 patients hospitalized during the study period, 13 (10 male) were diagnosed with spontaneous pneumomediastinum, constituting 0.39% of all hospitalizations. The median age was 37 years (interquartile range 20-55 years). The most common presenting symptom was dyspnea in 85% followed by neck swelling (69%), chest pain (69%) and cough (54%). Subcutaneous emphysema and preexisting lung diseases were identified in 11 (85%) patients each. Post-tubercular pulmonary sequelae (5 patients) and asthma (4 patients) were the most common underlying lung diseases. Pneumothorax was identified in 6 (46%) patients; 4 required tube thoracostomy. Chest radiography was diagnostic in 92% of patients. The median length of hospital stay was 9 days (interquartile range 6-12 days). No recurrence was reported in 11 patients followed up for a median of 1550 days (interquartile range 691-1909 days).

CONCLUSIONS

Spontaneous pneumomediastinum is a benign disorder, but underlying lung diseases and concomitant pneumothorax are likely to complicate the disease course. Exacerbation of post-tubercular obstructive airway disease is a common risk factor for spontaneous pneumomediastinum in a tuberculosis endemic country.

Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoscrotum: unusual complications of acute perforated diverticulitis

Pneumomediastinum, and subcutaneous emphysema usually result from spontaneous alveolar wall rupture and, far less commonly, from disruption of the upper airways or gastrointestinal tract. Subcutaneous neck emphysema, pneumomediastinum, and retropneumoperitoneum caused by nontraumatic perforations of the colon have been infrequently reported. The main symptoms of spontaneous subcutaneous emphysema are swelling and crepitus over the involved site; further clinical findings in case of subcutaneous cervical and mediastinal emphysema can be neck and chest pain and dyspnea. Radiological imaging plays an important role to achieve the correct diagnosis and extension of the disease. We present a quite rare case of spontaneous subcutaneous cervical emphysema, pneumomediastinum, and pneumoretroperitoneum due to perforation of an occult sigmoid diverticulum. Abdomen ultrasound, chest X-rays, and computer tomography (CT) were performed to evaluate the free gas extension and to identify potential sources of extravasating gas. Radiological diagnosis was confirmed by the subsequent surgical exploration.

Vomiting-induced surgical emphysema and pneumomediastinum: a self-remitting or life-threatening condition?

A previously well 18-year-old male presented with a 3-day history of vomiting, abdominal pain and increasing neck swelling. X-rays demonstrated both pneumomediastinum and cervical surgical emphysema and initial efforts were centred upon excluding Boerhaave syndrome (vomiting-induced oesophageal rupture). Upper gastrointestinal endoscopy and contrast CT scans excluded breech of the oesophagus but did, however, confirm dilated small bowel. Over the days, his condition did not improve, repeat CT demonstrated worsening small bowel dilatation and he eventually underwent laparotomy on day 5 of his admission. This revealed a high-grade obstruction in the right iliac fossa (presumably from a previous appendicectomy). Following adhesiolysis, he made a full recovery from both small bowel obstruction and surgical emphysema.

Air within the spinal canal in spontaneous pneumomediastinum

Spontaneous pneumomediastinum is an uncommon benign condition that is occasionally associated with air within the spinal canal. We describe a further case in a 14-year-old girl and suggest a classification system based on a detailed review of the previous literature. Forty-eight patients with spontaneous pneumomediastinum and intraspinal air accumulation (36 men and 12 women, age range 4-72 years, median age 18 years) were grouped into those with underlying lung disease (n = 13), those with other underlying etiologic factors (n = 22), and those arising spontaneously (n = 13). Neurologic symptoms or signs were noted in one case. The remaining cases were successfully managed conservatively. In spontaneous pneumomediastinum, accumulation of air within the spinal canal is self-limiting and benign. The same management is advised in spontaneous pneumomediastinum with and without intraspinal air accumulation.

Spontaneous pneumomediastinum: benefits of contrast computed tomography imaging

OBJECTIVE

We report a case of spontaneous pneumomediastinum presenting with chest and anterior neck pain.

METHOD

The clinical findings, differential diagnosis and selection of radiological investigations are discussed.

RESULTS

Spontaneous pneumomediastinum is an uncommon condition usually presenting in young patients. Presentation to the otolaryngology department occurs due to the presence of symptoms such as neck pain. Differential diagnoses must be considered and excluded, using the clinical features and the results of radiological investigation. Once the diagnosis is confirmed, conservative management is undertaken.

CONCLUSION

Spontaneous pneumomediastinum is uncommon and the clinical features are variable. The recommended investigation is a computed tomography scan with orally administered, water soluble contrast to exclude important differential diagnoses and thus enable definitive diagnosis.

Spontaneous pneumomediastinum: diagnostic and therapeutic interventions

OBJECTIVES

The objective of this case series is to review our experience with spontaneous pneumomediastinum, review the available literature, and refine the current clinical approach to this uncommon condition.

METHODS

The case notes of all patients admitted to the George Washington University Medical Center with spontaneous pneumomediastinum from April 2005 to June 2008 were retrospectively reviewed, indentifying seventeen patients on whom various data was collected and analyzed.

RESULTS

The typical patient is a young man. The commonest presenting complaint is chest pain. Odynophagia and subcutaneous emphysema are common. Leucocytosis is uncommon. The need for swallow studies, antibiotics, and prolonged hospitalization is uncommon. Most patients have no recurrences or sequelae on long-term follow-up.

CONCLUSION

Spontaneous pneumomediastinum is an uncommon, self-limiting condition. Due to concerns for the integrity of the aero-digestive tract, the finding of spontaneous pneumomediastinum usually results in unnecessary radiological investigations, dietary restriction and antibiotic administration with prolonged hospitalization.