Spontaneous pneumomediastinum

Spontaneous Subcutaneous Emphysema in a Teenage Male Extending As Pneumomediastinum, Pneumothorax, Pneumopericardium, and Epidural Pneumatosis: A Rare Combination of Anatomical Locations

Subcutaneous emphysema (SE) and pneumomediastinum can be spontaneous or traumatic in origin. Spontaneous SE involving cervical, parapharyngeal, mediastinal, pericardial, and pleural space together is rare, while epidural pneumatosis is an even rarer entity. We report a previously healthy teenage male with sudden onset chest pain whose plain radiographs and high-resolution computed tomography (HRCT) showed extensive spread of air in the mediastinum, pericardial space, pleural space, and epidural space. He was hemodynamically stable and had a spontaneous recovery after one week. Follow-up radiological imaging showed complete radiological resolution of gas lucencies. It is quite important for clinicians to be aware of this condition, common and rare routes of extension, and possible complications. Clinical suspicion is vital to plan appropriate investigations especially radiological modalities such as chest X-ray and HRCT. This will help in evaluating the severity of the condition, exclude possible etiologies, and look for potential complications so that proper management and follow-up can be planned.

Silent Dyspnea: Spontaneous Pneumomediastinum in a Heroin User

Spontaneous pneumomediastinum (SPM) is a relatively rare presentation that often follows a benign clinical course. It is mainly triggered by underlying bronchial asthma, respiratory tract infections, strenuous activities, or illicit drug use. We present a case of an isolated primary pneumomediastinum where the patient was a 24-year-old man with underlying bronchial asthma who presented with acute onset of shortness of breath and pleuritic chest pain following snorting of an opioid-heroin. Although the clinical exam and chest radiograph were both unremarkable, the multi-detector computed tomography of the chest revealed an isolated pneumomediastinum. The patient was managed conservatively in accordance with existing evidence as SPM is known for its spontaneous recovery.

Pneumomediastinum in a cannabis smoker precipitated by vigorous sexual intercourse

Primary pneumomediastinum is the presence of air in the interstitium of the mediastinum. The exact aetiology is unclear; nevertheless, it has been reported more frequently in patients with asthma and in individuals who use recreational drugs. It is commonly preceded by a sharp rise in intrathoracic pressure as in a Valsalva-like manoeuvre. We describe a rare case of severe pneumomediastinum with a small pneumothorax related to cannabis smoking and aggravated by vigorous sexual intercourse. The patient was successfully treated conservatively due to clinical and radiological stability and the absence of secondary cause.

Spontaneous pneumomediastinum: an uncommon clinical problem with a potential for missed or delayed diagnosis

A 15-year-old man presented with an acute history of facial swelling following a bout of forceful eructation after eating. Subcutaneous emphysema was noted on examination of his left face and neck. He was initially managed with intravenous antibiotics for suspected facial infection. A chest radiograph performed on day 3 of admission identified subcutaneous emphysema of the upper thorax and neck. CT with oral contrast confirmed extensive subcutaneous emphysema of neck, thorax and upper abdomen, with associated pneumomediastinum. The site of air leak was not identified. He subsequently underwent upper gastrointestinal endoscopy and this was normal. Despite the delay in diagnosis, he remained haemodynamically stable, and repeated radiography showed improvement reflecting the benign course of this condition as described in existing literature. There are no previous published reports of spontaneous pneumomediastinum following eructation; therefore, high clinical suspicion should be maintained in this presentation.

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.

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Pneumomediastinum is a rare complication of Hyperemesis Gravidarum.

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

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

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Spontaneous pneumomediastinum can often be treated conservatively.

Silent Breathlessness: A Case and Brief Review of Spontaneous Pneumomediastinum

Spontaneous pneumomediastinum is an uncommon diagnosis defined as the presence of free air in the mediastinum without an apparent cause. It is a self-limiting disorder that most often occurs in young males without any apparent precipitating factor or underlying disease process. Its pathophysiology involves the rupture of alveoli with resultant air penetration into the mediastinum. Underlying disease processes, such as asthma, physical trauma, including yelling, contact sports, and Valsalva during labor, have also been reported to cause spontaneous pneumomediastinum. Here, we present the case of an 18-year-old male who presented to us with the chief complaint of cough and the subsequent diagnosis of spontaneous pneumomediastinum.

A Case of Spontaneous Pneumomediastinum with Subcutaneous Emphysema in Children

Spontaneous pneumomediastinum is defined as free air or gas contained within the mediastinum, which almost invariably originates from the alveolar space or the conducting airways. It is rare in pediatric patients; however, occasional cases are reported to result from forced Valsalva’s maneuver due to cough, emesis, a first attack of wheeze, or asthma exacerbations. We report the case of a 7-year-old previously healthy girl, with a history of persistent dry cough one day before, who was brought to our unit with face, neck and chest swelling. The chest X-ray and computed tomography (CT) scan showed subcutaneous emphysema with pneumomediastinum and pneumopericardium without evidence of the origin of this air leak. Laboratory tests and the bronchoscopy were normal. The patient was admitted in the pediatric critical care and received noninvasive monitoring, analgesia, oxygen, and omeprazole as a prophylaxis for a gastric ulcer. The patient improved, subcutaneous emphysema resolved, and she was discharged on the third day.

Spontaneous pneumomediastinum and subcutaneous emphysema as a complication of asthma in children: case report and literature review

Background:

Spontaneous pneumomediastinum (SPM) is an uncommon disorder. It is rarely reported in paediatric patients and may be accompanied by subcutaneous emphysema. It is usually benign and self-limiting, with only supportive therapy being needed, but severe cases may require invasive measures. Asthma exacerbations have classically been described as a cause of SPM. However, detailed descriptions in asthmatic children are scarce. We aimed at improving the current understanding of the features of SPM and subcutaneous emphysema, and outcomes, by means of a case report and a systematic review.

Methods:

For the systematic review a literature search was performed in PubMed to identify reported cases of SPM in asthmatic children.

Results:

The case a 10-year-old asthmatic girl with SPM is reported. The patient received an inhaled corticosteroid and long-acting beta2 agonist, in addition to sublingual immunotherapy (SLIT) with eventual control of asthma symptoms. Review: A total of 114 published cases were found since 1995, most of them in teenagers; no sex differences were observed. Clinical presentation was associated with an asthma exacerbation in a number of cases. Other presenting features were chest pain, dyspnoea, cough, and particularly acute swelling of the face, neck, and upper chest. Subcutaneous emphysema was present in most patients. Overall, three cases of pneumothorax and two cases of pneumorrhachis were reported. Therapy was mainly based on supportive care, rest, oxygen therapy, analgesics, steroids, and bronchodilators. All patients recovered spontaneously, in spite of a small initial increase in SPM in a few cases.

Conclusions:

Early identification of patients at risk of SPM would avoid the high number of under-diagnosed cases. Patients should be treated not only with supportive therapy but also with measures to achieve control of the underlying cause (such as poorly controlled asthma).

Three Simultaneous Cases of Spontaneous Pneumomediastinum With Epidural Pneumatosis During Vocal Training

OBJECTIVE

The aim of this study was to describe a case series of three simultaneous cases of spontaneous pneumomediastinum (SPM) with epidural pneumatosis during vocal training.

METHODS

A report of three cases with chart review was performed. Literature review was carried out using PubMed.

RESULTS

This was an extremely rare case series where at least three of the 20 participants of a vocal training in a self-development seminar developed SPM, epidural pneumatosis, pneumothorax, and subcutaneous emphysema. All cases improved with bed rest. Simultaneous cases of SPM have been reported in the past. However, the cause of simultaneous occurrence has not been explained clearly. In our cases, continuous excessive vocal training may have caused intrathoracic pressure to rise, causing SPM at a high prevalence. Epidural pneumatosis is a rare finding. Studies on epidural pneumatosis complicating SPM are limited. Air is said to easily pass through the cervical region owing to the close proximity between the mediastinum and the upper spine, resulting in epidural pneumatosis. Elevated intrathoracic pressure while the glottis is closed may worsen the risk for epidural pneumatosis. In this seminar, continuous effortful vocal training at full pitch with few pauses for breath may have contributed to this simultaneous occurrence.

CONCLUSIONS

We report three simultaneous cases of SPM and epidural pneumatosis due to demanding vocal training. Further research on this subject is desired to identify risk factors.

Management of spontaneous pneumomediastinum in children

PURPOSE

We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway.

METHODS

All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome.

RESULTS

We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7-16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n=91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1-2) for non-ICU admissions and 3 days (IQR: 2-3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38-1.50, p=0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n=81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis).

CONCLUSION

Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.

Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography

Spontaneous pneumomediastinum (SPM) is described as free air or gas located within the mediastinum that is not associated with any noticeable cause such as chest trauma. SPM has been associated with many conditions and triggers, including bronchial asthma, diabetic ketoacidosis, forceful straining during exercise, inhalation of drugs, as well as other activities associated with the Valsalva maneuver. The Macklin effect appears on thoracic computed tomography (CT) as linear collections of air contiguous to the bronchovascular sheaths. With the recent availability of multidetector-row CT, the Macklin effect has been seen in the clinical setting more frequently than expected. The aim of this review article is to describe the CT imaging spectrum of the Macklin effect in patients with SPM, focusing on the common appearance of the Macklin effect, pneumorrhachis, and persistent SPM with pneumatocele.

Pneumomediastinum from a severe asthma attack

Spontaneous pneumomediastinum is a rare complication of an asthma exacerbation characterized by chest pain, dyspnea, neck swelling, and subcutaneous emphysema. Although the condition is usually benign and treatment is primarily supportive, surgical intervention may be needed if the patient develops hemodynamic or respiratory failure.

Pneumomediastinum and pneumothorax after orthognathic surgery -A case report-

The occurrences of pneumomediastinum and pneumothorax after oral and/or maxillofacial surgery are rare, but both are potentially life-threatening complications. Most of the cases that present pneumomediastinum and pneumothorax in the oral and/or maxillofacial surgery result from air dissecting down the fascial planes of the neck. We report a case of a 23-year-old male patient who underwent bilateral sagittal split ramus osteotomy under general anesthesia and developed pneumomediastinum and pneumothorax without any traumatic introduction of air through the cervical fascia three days postoperatively. The possible causes and its prevention are discussed with a review of the relevant literature.

Spontaneous pneumomediastinum (Hamman's syndrome)

INTRODUCTION

Spontaneous pneumomediastinum is defined as the presence of free air in the mediastium in the absence of any obvious precipitating cause. The purpose of this study was to review our experience with this condition, discuss mechanisms and provide a management algorithm.

METHODS

A retrospective audit of patients admitted with spontaneous pneumomediastinum between 2003 and 2008 was performed. A total of 17 patients were identified.

RESULTS

Common predisposing factors for spontaneous pneumomediastinum were alcohol excess, asthma and illicit drug use. Vomiting and coughing were common precipitating factors. There was no morbidity, mortality or recurrence. Patients were admitted under a number of different specialties.

DISCUSSION

Spontaneous pneumomediastinum is a benign self-limiting condition that requires early differentiation from more serious causes, in particular Boerhaave's syndrome.

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.

A 15-year-old boy with anterior chest pain, progressive dyspnea, and subcutaneous emphysema of the neck

We describe the case of an adolescent who was admitted to the hospital because of sudden occurrence of chest pain, dyspnea and subcutaneous emphysema. On admission, physical examination revealed subcutaneous crepitations in the superior part of the rib cage, and auscultation of the chest showed widespread wheezing. The radiological assessment confirmed the diagnosis of pneumomediastinum and pneumothorax. A follow-up CT scan performed one week after the admission showed almost complete resolution of the radiological alterations. At the following visits, the patient was asymptomatic, but reported to have suffered from frequent episodes of rhinorrea, sneezing, nasal blockage, and sometimes, chest tightness, especially during exposure to pets and/or windy weather. Skin prick testing showed sensitivities to dermatophagoides pteronyssinus and farinae, grass pollen and dog dander. Spirometry documented significant improvement in lung function after short-acting bronchodilator, allowing for the diagnosis of asthma to be made. Although pneumomediastinum may be a complication of various respiratory diseases, including asthma, it has never been reported as the first presentation of underlying bronchial asthma. Herein, the physiopathological mechanisms, the diagnostic procedures and treatment of pneumomediastinum in asthma are discussed. We suggest that the diagnosis of asthma should be considered in the differential diagnosis of pneumomediastinum in adolescence.

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

Spontaneous pneumomediastinum is an uncommon, self-limiting condition resulting from alveolar rupture in young adults. Because of the ambiguous presentation and the general lack of awareness of this condition, its diagnosis is often delayed, missed, or confused with spontaneous esophageal perforation. We report our experience of treating six patients who were referred to our unit with vomiting-induced pneumomediastinum, subcutaneous emphysema, and an initial diagnosis of spontaneous esophageal perforation. Ultimately, we diagnosed spontaneous pneumomediastinum in all six patients, who recovered uneventfully without any surgical intervention. We review the literature with particular emphasis on differentiating spontaneous pneumomediastinum from spontaneous esophageal perforation.

Spontaneous pneumomediastinum: a benign curiosity or a significant problem?

OBJECTIVE

To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management.

METHODS

A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated.

SETTING

The emergency department referrals of two major Melbourne teaching hospitals.

RESULTS

SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.

Sports-related spontaneous pneumomediastinum

BACKGROUND

Spontaneous pneumomediastinum is a rare medical entity occurring almost exclusively in otherwise healthy young individuals without known predisposing factors. We reported our experience with patients presenting with spontaneous pneumomediastinum related to sports.

METHODS

Between January 1991 and December 2002, 10 patients were admitted with spontaneous pneumomediastinum related to sporting activities. We retrospectively reviewed their medical records with regard to predisposing factors, clinical presentation, diagnostic evaluation, and outcome.

RESULTS

The mean age of our patients was 18.9 years (range 15 to 25 years). Retrosternal chest pain was the most common symptom (90%), and subcutaneous emphysema the most common physical finding (90%). Hamman's sign was present in 9 patients. In all 10 patients, physical exertion during sports was the only implicating factor (scuba diving in 4 patients, basketball in 2, soccer in 3, and volleyball in 1). All patients were treated conservatively. Complete resorption of the pneumomediastinum occurred in 3 to 8 days. Hospital stay ranged from 2 to 6 days (mean 3.8 days). Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Only 1 recurrence of pneumomediastinum was found that was treated similarly.

CONCLUSIONS

Spontaneous pneumomediastinum after sporting activities is a benign disease that generally resolves without clinical sequelae. Restriction of physical and athletic activity after the first episode is unnecessary, the only exception being that of scuba diving.

Spontaneous pneumomediastinum long-term follow-up

BACKGROUND

Spontaneous pneumomediastinum (SP) is a rare disorder.

METHODS

The objective of this study is to examine a series of patients treated during 19 years, analyzing risk, clinical, and diagnostic factors as well as treatment and long-term follow-up.

MATERIALS AND METHODS

A descriptive, retrospective study was done from 1984 to 2003 on 32 patients admitted to the hospital with SP.

RESULTS

The average age was 21.4+/-6.1 years, 24 (75%) males. 34.4% had developed some strain before arriving at the hospital. Nine of the cases were asthmatic (28.1%) and another nine were smokers (28.1%). The most frequent complaint was thoracic pain, 25 (78.1%). In the physical examination, subcutaneous cervical emphysema was observed in 25 patients (78.1%). A simple X-ray of the thorax was used in the diagnosis of 32 cases. In two patients, radiological signs of pneumothorax were discovered. An esophagogram was done on two patients but there were no significant findings. All of the cases were treated conservatively. The average hospital stay was 3.2+/-1.6 days. No relapses were noted in the follow-ups.

CONCLUSION

SP is an entity that evolves correctly without treatment and has no long-term relapses. Once other occasionally associated entities are ruled out, outpatient management can be employed.

Spontaneous pneumomediastinum: are we overinvestigating?

BACKGROUND

Spontaneous pneumomediastinum (SPM) is uncommon in pediatrics. Because of the growing concern about the risks of radiation in children, the authors analyzed whether an extensive radiologic workup influences management and outcome.

METHODS

In a retrospective study from 1991 to 2003, 53 patients were diagnosed with SPM. Charts were reviewed for demographics, predisposing factors, presentation, investigation, and evolution. Pneumomediastinum occurring in the neonatal period or related to either pneumothorax, barotrauma, or trauma were excluded.

RESULTS

Of 53 cases, 26 (49%) were bronchospasm related, 11 (21%) had respiratory tract infections, and 8 (15%) were idiopathic. Four (7.5%) were caused by inhaled foreign bodies while other causes accounted for the remaining 7.5%. No esophageal perforations were identified. Presentations included dyspnea (64%), subcutaneous emphysema (60%), cough (45%), cervical or chest pain (42%), and Hamman's sign (19%). Postero-anterior chest x-rays (CXR) were diagnostic in all cases except one. Mean number of CXR per hospitalization was 3. Only 3 patients subsequently had pneumothorax, and none required pleural drainage. Of the 8 patients with idiopathic SPM, 5 underwent a barium swallow, and 2 had a chest CT scan; results of all were normal.

CONCLUSIONS

More than 70% of SPMs were related to bronchospasm or respiratory tract infections. Idiopathic SPMs deserve more attention because of the concern about esophageal perforation, although most investigations will be negative. SPM usually is a self-limited condition, and prognosis is related to the underlying disorder. Consequently, with clinical improvement, aggressive investigation and follow-up x-ray rarely is warranted.

Spontaneous pneumomediastinum: a rare benign entity

OBJECTIVE

Spontaneous pneumomediastinum usually occurs in young people without an apparent precipitating factor or disease. Thoracic surgeons are involved in the diagnosis and management of this entity because of the potentially life-threatening conditions that either must be treated as an emergency or excluded, such as esophageal perforation or necrotizing mediastinitis. We present our modest experience in treating spontaneous pneumomediastinum.

MATERIALS

Between 1988 and 1998 we treated 22 cases of spontaneous pneumomediastinum in 18 male patients and 4 female patients, ranging in age between 12 and 32 years. All traumatic cases were excluded. Retrosternal chest pain was the main symptom the patients presented. In only 11 cases was subcutaneous emphysema present. Chest radiography was diagnostic in all our cases. Computed tomographic scan, when performed, confirmed the diagnosis. An esophagogram was essential to exclude an esophageal rupture. Last, a cardiologic examination especially focusing on pericarditis excluded cardiac disease.

RESULTS

Conservative treatment consisted of bed rest, oxygen therapy, and analgesics, which led to rapid resolution of the spontaneous pneumomediastinum. The mean hospital stay ranged between 3 and 10 days. In a follow-up of 3 to 12 years only 1 recurrence was observed.

CONCLUSION

Spontaneous pneumomediastinum is usually an undiagnosed benign entity that responds very well to conservative treatment. It should be considered in the differential diagnosis of chest pain, especially in healthy adolescents and young adults.

Spontaneous pneumomediastinum in children

SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

Atypical presentation of spontaneous pneumomediastinum

Spontaneous pneumomediastinum is a rare clinical entity; when diagnosis is certain, no treatment is required and symptoms rarely recur. The clinical presentation is usually diagnostic; however, atypical symptoms may mandate further investigation before diagnosis can be established. We describe 2 patients with spontaneous pneumomediastinum who presented with dominant esophageal symptoms (odynophagia and dysphagia) suggestive of esophageal perforation. Investigation and management are discussed.

Spontaneous pneumomediastinum. A report of 25 cases

Spontaneous pneumomediastinum (SPM) is a relatively uncommon, infrequently reported entity. To determine the clinical presentation and sequelae of SPM, data were obtained from 25 patients: 14 from Hadassah University Hospital, and 11 from other medical institutions. The mean age was 18.8 +/- 5.2 years (+/- SD), with a range of 8 to 31 years. The most common presenting complaint was retrosternal pain in 22 patients (88 percent), dyspnea in 15 (60 percent), dysphagia in 10 (40 percent), and weakness in 10 (40 percent). Predisposing factors for the development of SPM could be identified in 18 patients (72 percent). Information on the sequelae of SPM during a mean period of 87.4 +/- 38.0 months following the initial SPM episode was obtained from 23 patients. Recurrent SPM occurred in 1 patient at 18 months, and another patient experienced 4 episodes of recurrent spontaneous pneumothorax. No other long-term sequelae were reported. We conclude that SPM is a benign self-limited disease with diverse clinical manifestations. Although uncommon, recurrences of SPM may be observed.

Spontaneous pneumomediastinum in children

Spontaneous pneumomediastinum is defined as a non-traumatic mediastinal air leak in patients without underlying lung disease. In children it is rarely diagnosed but is likely to be often missed. We have made a comprehensive review of the literature on spontaneous pneumomediastinum in children. The aetiopathogenesis, incidence, clinical features, diagnosis and treatment are discussed. We suggest that spontaneous pneumomediastinum in children is underdiagnosed.

Spontaneous pneumomediastinum: is it a rare cause of chest pain?

A policy of obtaining a routine chest radiograph in every young patient with unexplained chest pain or dyspnoea led to the diagnosis of 14 cases of spontaneous pneumomediastinum within four years, whereas only two cases from former years could be found retrospectively. One patient had recurrent spontaneous pneumomediastinum, the first case so far reported. Analysis of admission data suggested that this entity may be much more common than is generally believed, and may be second only to spontaneous pneumothorax as a cause of admission of young, healthy individuals experiencing sudden chest pain or shortness of breath. After reviewing the published reports we propose the following definition of spontaneous mediastinal emphysema: the non-traumatic presence of free air in the mediastinum in a patient with no known underlying lung disease. When it occurs without associated pneumothorax it is benign. The incidence of spontaneous pneumomediastinum for the four-year period under study was 1 per 12 850 admissions.

Air in unusual places: some causes and ramifications of pneumomediastinum

Five unusual cases of pneumomediastinum are described. In three the probable cause was thoraco-abdominal straining against a closed glottis during violent exercise, in criminal assault, or competitive sport. The resultant increase in intra-alveolar pressure produces an air leak which passes via the pulmonary interstitium into the mediastinum. It can then pass up into the neck to produce widespread subcutaneous emphysema and down through the diaphragmatic hiatuses to produce extraperitoneal emphysema. This may outline the lower surface of the diaphragm to stimulate intraperitoneal air, but it can also leak through the parietal peritoneum to result in actual intraperitoneal air. Therefore, in the patient who has been hospitalised after violent physical stress with or without blunt trauma, pneumomediastinum does not necessarily indicate tracheobronchial or oesophageal rupture and subdiaphragmatic air does not necessarily indicate bowel rupture. Probably any form of exercise in which the Valsalva manoeuvre is performed may cause pneumomediastinum, as may other causes of increased intra-alveolar pressure such as mechanical ventilation, bronchospasm, coughing and vomiting. Vomiting is a likely contributing cause in the pneumomediastinum of diabetic ketosis, of which a case is described. Another case is presented in which air passed in the opposite direction, from perforated extraperitoneal bowel up into the mediastinum.

Pneumomediastinum following the Heimlich maneuver

The Heimlich maneuver appears to be a widely accepted technique advocated as a means of clearing an obstructed airway. Reports of complications have been few. We report a case of pneumomediastinum that occurred following the generation of increased pulmonary pressures during performance of the Heimlich maneuver.