Pneumomediastinum presenting as acute airway obstruction

Acute Upper Airway Obstruction Due to Massive Cervical Subcutaneous Emphysema: A Case Report

With upper airway obstruction being an emergency, a high index of suspicion and proper and timely treatment planning are crucial to the patient's life. Spontaneous esophageal perforation, also known as Boerhaave syndrome, has been observed to cause subcutaneous emphysema; however, airway compromise secondary to subcutaneous emphysema is extremely rare when there is no associated broncho-tracheal injury. Here, we present a case of esophageal perforation complicated with cervical emphysema that led to acute airway obstruction requiring invasive ventilation.

A Case Report of Acute Airway Compromise due to Subcutaneous Emphysema

In the acute management of a trauma patient, airway patency is of utmost importance. The present case describes a male patient who presented with delayed severe upper airway obstruction secondary to massive subcutaneous emphysema following blunt traumatic injury two days previously. Airway compromise is a rarely described but serious complication of subcutaneous emphysema. Current management of subcutaneous emphysema and its association with pneumothorax is summarized. Early decompression of underlying pneumothoraces in patients with significant subcutaneous emphysema should be performed to avoid this rare complication.

Spontaneous Pneumomediastinum: An Uncommon Complication from an Augmented Physiological Belching (Imitating a TV Show Game)

Noisy belching in front of other people, often considered to be an impolite manner, may not be as harmless as it seems. We report on a patient who had spontaneous pneumomediastinum after intentional induction of noisy belching by rapid excessive intake of carbonated drinks (imitating the game played in a popular local television program “The Super Trio Continues…”). The clinical features, investigations and management of spontaneous pneumomediastinum are discussed.

Clinical analysis of spontaneous pneumomediastinum

Background

Spontaneous pneumomediastinum is a rare and benign condition that generally occurs in young generations without any precipitating factor or underlying disease. The purpose of this study is to review our experience in dealing with this entity and detail a reasonable course of assessment and management.

Methods

From December 1999 to May 2012, 32 spontaneous pneumomediastinum patients were managed in our hospital. We retrospectively reviewed the result of management.

Results

Patients ranged in age from 10 to 38 years, with the mean age of 18.3±5.6 years. Twenty-five patients were men and seven were women. Initial WBC count was 10,039±2,993/µL and thirty-one patients underwent computed tomography. Twenty-two patients underwent esophagography and results were shown to be normal. Twenty-five patients were admitted in the hospital and the mean duration of admission was 3.4±2.0 days. All patients were managed conservatively and discharged without any complications.

Conclusion

Spontaneous pneumomediastinum is a benign condition combined with mild inflammatory signs and secondary causes must to excluded to avoid unfavorable outcomes and select proper management modality.

[Massive subcutaneous emphysema--management using subcutaneous drains]

Massive subcutaneous emphysema is a relatively common complication in invasive techniques, surgical practice and some medical conditions. Subcutaneous emphysema is usually treated conservatively and may only cause minimal symptoms. Even when it is severe, subcutaneous emphysema rarely has pathophysiologic consequences, but it is extremely uncomfortable for the patient. The authors report a case of massive and rapid developing subcutaneous emphysema following chest tube displacement in a patient with spontaneous se- condary pneumothorax and large air leak. The emphysema was treated with two subcutaneous drains, inserted using local anesthesia, on both sides of the chest (antero -superior thoracic wall), connected to drainage bags. The drains produced a dramatic clinical improvement and provided effective decompression of the subcutaneous emphysema. In this clinical case, the technique of drainage of severe subcutaneous emphysema using subcutaneous drains was safe, easy and effective, affording immediate symptom relief.

[Case of pharyngeal emphysema with airway obstruction during retroperitoneal laparoscopic nephroureterectomy]

A 76-year-old woman with right renal pelvic cancer underwent a laparoscopic nephroureterectomy via a retroperitoneal approach. During the 300 minutes of CO2 insufflation, arterial blood pressure, temperature, and oxygen saturation were stable, whereas the end-tidal CO2 (ETCO2) gradually increased and reached a peak of 55 mmHg. Her arterial blood gas analysis suggested acute respiratory acidosis. She developed hypercapnia in spite of controlled hyperventilation in response to the increasing ETCO2. Skin crepitus was extending into the neck and face from the operative site. A portable chest radiograph taken postoperatively showed pneumomediastinum and extensive subcutaneous emphysema of neck and chest wall. Laryngoscopy revealed grossly emphysematous pharyngeal tissues preventing direct vocal cord visualization. Her airway was appeared to be totally occluded by markedly edematous laryngeal tissues. As a leak sound around the tracheal tube was not heard after deflation of the tube cuff, her pharyngeal swelling was suspected to be severe and tracheal extubation during the operation was postponed. When cervicofacial emphysema occurs intraoperatively, we recommend that laryngoscopy should be performed before tracheal extubation to avoid potential airway obstruction from associated pharyngeal emphysema.

Upper airway obstruction as a result of massive subcutaneous emphysema following accidental removal of an intercostal drain

A case is described of extensive subcutaneous emphysema with rapid and life-threatening airway obstruction. The incident followed inadvertent removal of a chest drain in a patient with a persistent air leak from an iatrogenic pneumothorax. The pneumothorax had developed during pacemaker insertion.

Rhinolalia as a presenting sign of pneumomediastinum complicating post peripheral blood stem cell transplantation bronchiolitis obliterans

A 26-year-old male with graft vs. host disease (GVHD) presented with rhinolalia (a squeaky voice of nasal quality) as a presenting sign for pneumonasopharynx and pneumomediastinum secondary to bronchiolitis obliterans. The patient underwent HLA-identical related peripheral blood stem cells transplantation 8 months before the diagnosis. Three weeks after transplantation he began to suffer from GVHD Grade III that involved the gut, liver, and skin and later on the lungs. Due to severe obstructive bronchiolitis obliterans the patient developed intensive cough evolving into pneumomediastinum and pneumonasopharynx with rhinolalia. The patient was treated conservatively with complete resolution. Although rare, pneumomediastinum and pneumonasopharynx can be a life-threatening event, and one should be aware of the signs and symptoms on physical examination, which may be as subtle as rhinolalia alone.

Pneumomediastinum after dental surgery

A previously healthy woman presented with chest pain and cervical swelling several hours after undergoing surgical removal of third molar teeth. Mediastinal and subcutaneous emphysema was demonstrated by chest X-ray. Air had been introduced under the soft tissue flap by the high-speed turbine drill used to remove the alveolar bone, rather than the air/water syringe. Surgical handpieces that vent the air away from the surgical field should be used during such procedures. The mediastinal and subcutaneous air resolved after oxygen administration.

Pneumomediastinum acquired by glass blowing

Pneumomediastinum is uncommon. We present a case of spontaneous pneumomediastinum, which occurred in a young man whose profession is glass blowing. He presented not only with typical complaints of chest pain and odynophagia, but also with the unusual complaint of a "foreign body" sensation in the middle of his chest.

[Spontaneous pneumomediastinum in an adolescent: an underestimated cause of chest pain]

CASE REPORT

A case of mediastinal emphysema occurring without etiologic factor except a Valsalva's manoeuvre a few hours before admission in a 15-year-old boy is reported. Symptoms were cervical and chest pain with moderate dysphagia. Diagnosis was confirmed by palpating subcutaneous air in the neck region and mediastinal air on a chest roentgenogram. A CT scan was performed to exclude a concurrent pneumothorax. The patient recovered with bed rest.

CONCLUSION

Spontaneous pneumomediastinum results from nontraumatic, mediastinal air leakage without underlying lung disease. It should be considered in the differential diagnosis of chest pain, especially in healthy adolescents and young adults; it is certainly underdiagnosed in this population.