Spontaneous pneumomediastinum long-term follow-up

A Rare Complication during Vaginal Delivery, Hamman's Syndrome: A Case Report and Systematic Review of Case Reports

Background: Spontaneous pneumomediastinum (SPM) during pregnancy or labor is a rare event. We presented a case report and a systematic review of the literature to provide comprehensive symptoms, treatments, and complications analysis in the pregnant population affected by SPM. Methods: We conducted a comprehensive search of four databases for published papers in all languages from the beginning to 1 September 2021; Results: We included 76 papers with a total of 80 patients. A total of 76% patients were young primiparous, with a median age of 24 ± 5.4 years. The median gestational age was 40 ± 2.4 weeks, with a median duration of labor of 7.4 ± 4.2 h. In 86%, the ethnic origin was not specified. SPM develops in 55% of cases during the second stage of labor. Subcutaneous swelling and subcutaneous emphysema were present in 91.4%. Chest pain and dyspnea were present in 51.4% and 50% of the patients, respectively. We found that 32.9% patients had crepitus, and less common symptoms were dysphonia and tachycardia (14.3% and 14.3%, respectively). Oxygen and bronchodilators were used in 37.7% of the cases. Analgesics or sedatives were administered in 27.1%. Conservative management or the observation was performed in 21.4% and 28.6%, respectively. Antibiotics treatment was offered in 14.3%, whereas invasive procedures such as chest-tube drainage were used in just 5.7% of patients. There were no complications documented in most SPM (70.0%). We found that 16.7% of the SPM developed a pneumothorax and 5% developed a pneumopericardium.; Conclusions: In pregnancy, SPM occurs as subcutaneous swelling or emphysema during the second stage of labor. The treatment is usually conservative, with oxygen and bronchodilators and a low sequela rate. A universal consensus on therapy of spontaneous pneumomediastinum in pregnancy is necessary to reduce the risk of complications.

A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem

Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term "Mediastinal Emphysema"[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.

Spontaneous primary pneumomediastinum: is it always benign?

BACKGROUND

Spontaneous Pneumomediastinum is a rare disease. It could be a simple and self-limited condition or be a life-threatening complication of underlying diseases. The therapeutic options also differ by the cause. This systematic review was done to provide, as far as we know, the first attempt to broadly assess the clinical feature, predisposing factors, possible management, and outcome of spontaneous primary pneumomediastinum.

METHODS

In addition to the two patients treated at our hospital, a Pub Med Search for literature on case reports of spontaneous pneumomediastinum published in English up to November 2018 was done. We extracted data on patients' demographic characteristics, symptoms, timing, diagnosis, management, and outcome of the treatment were analyzed based on the preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) RESULT: A total of 339 cases were reviewed. 71.7% of them were male. The Mean age affected was 22.4 ± 11.3 years. Chest pain, 196 (57.8%), is the most common presenting symptom, followed by dyspnea, 156 (46%), cough 95 (28%), neck swelling 92 (27.13%), cervical pain 88 (25.9%), dysphagia 39 (11.5%), odynophagia 37 (10.9%), and Dysphonia 14 (4.1%). Fifty-seven patients (16.8%) had a prior history of Asthma, 19 (5.6%) had Connective Tissue Disorders, and 12 (3.5%) had associated malignancy as an identified risk factor. In 35 (10.3%) patients, spontaneous pneumomediastinum was found incidentally. The mean number of days before the clinical resolution of spontaneous pneumomediastinum was 6.65 ± 11.8 days and the average hospital stay was 4.15 ± 1.93 days. Nineteen (5.6%) patients have died as a result of the underlying disease not related to SPM.

CONCLUSION

Spontaneous pneumomediastinum is uncommon, usually benign, a self-limited disorder that commonly occurs in a young adult without any apparent precipitating factor or disease. Spontaneous pneumomediastinum usually responds very well to conservative treatment without recurrence. However, secondary causes should be ruled out to minimize the unfavorable outcome.

Spontaneous Pneumomediastinum in an Adolescent Soccer Player

Spontaneous pneumomediastinum (SPM) is an uncommon and usually benign self-limiting clinical disorder found in young people, often without apparent precipitating factors or diseases. A pressure gradient exists between the peripheral pulmonary alveoli and the hilum, and increased intra-alveolar pressure causes rupture of the terminal alveoli. We present the case of a 15-year-old male soccer player who presented with a complaint of anterior chest pain and dysphagia after stopping the strong ball with his chest. His symptom gradually progressed over hours. We can make the diagnosis of SPM using by chest X-ray and computed tomography (CT) scanning. His symptoms were gradually resolved over the course of approximately one week with no exercise and careful observation. We believe that our case provides very useful information to alert clinicians and coaches regarding this rare disease that may occur in anyone including adolescent soccer players.

Spontaneous pneumomediastinum incidence and clinical features in non-intubated patients with COVID-19

OBJECTIVES

To evaluate the presentation characteristics and disease course of seven patients with COVID-19 who spontaneously developed pneumomediastinum without a history of mechanical ventilation.

METHODS

A total of seven non-intubated patients with COVID-19, of age ranging from 18-67 years, who developed spontaneous pneumomediastinum between 01 April and 01 October 2020 were included in the study. Patients' demographic data, clinical variables, and laboratory values were examined. Spontaneous pneumomediastinum was evaluated using posteroanterior chest radiography and thorax computed tomography.

RESULTS

During the research period, 38,492 patients reported to the emergency department of our hospital with COVID-19 symptoms. Of these, spontaneous pneumomediastinum was detected in seven patients who had no previous history of intubation. Chronic obstructive pulmonary disease (2/7) and asthma bronchiale (2/7) were determined as the most common causes of comorbidity.

CONCLUSIONS

In our study, the frequency of spontaneous pneumomediastinum developing without pneumothorax was found to be high in non-intubated patients. Whether this is related to the nature of the disease or it is a result of the increase in cases diagnosed incidentally owing to the increasing use of low-dose computed tomography should be explored in further studies.

Spontaneous Pneumomediastinum in a Teenager After Physical Exercise: a Benign and Rare, but Sometimes Challenging, Entity

Introduction

Pneumomediastinum defines a condition in which free air is present in the mediastinum usually caused by alveolar rupture resulting from a sudden increase in the intrathoracic pressure and air tracking along the tracheobronchial tree.

Case report

We present a case of a 16-year-old male patient referred to our department due to persisting odynophagia, and retrosternal chest pain. A performed chest-CT revealed presence of free air in the mediastinum, without evidence of pneumothorax, or subcutaneous emphysema. Under the diagnosis of spontaneous pneumomediastinum (SPM) the treatment included conservative therapy with analgesics, rest, and oxygen.

Conclusion

SPM is a rare benign condition with nonspecific presenting clinical signs; thus its diagnosis remains mostly one of exclusion. Thorough history-taking, beside radiographic studies, may be the key to confirm the diagnosis.

Spontaneous pneumomediastinum, pneumopericardium and subcutaneous emphysema in a case of interstitial pneumonia with autoimmune features

Spontaneous Pneumomediastinum (SPM) is a benign, self-limiting but potentially fatal condition specially in underlying pulmonary disease. Spontaneous pneumomediastinum is rarely associated with connective tissue related interstitial lung disease. We report a patient of interstitial pneumonia with autoimmune features who presented with acute onset breathlessness and was diagnosed to have spontaneous pneumomediastinum, pneumopericardium, and subcutaneous emphysema. This condition are easily diagnosed by clinical findings like Hamman's crunch and plain chest radiographs in cases with normal underlying lungs. In cases of extensive pulmonary fibrosis like Interstitial Lung Diseases both clinical findings and Plain chest radiographs can be inconclusive. CT of thorax is the gold standard diagnostic modality. Pneumopericardium rarely leads to cardiac tamponade, which requires immediate surgical intervention. We conclude that every case of acute onset breathlessness in a known case of interstitial lung disease may not necessarily be an exacerbation of the underlying lung condition. Physicians need to have a high index of suspicion while treating patients of interstitial lung disease. CT thorax is gold standard diagnostic modality especially in presence of fibrotic lung diseases.

Spontaneous Pneumomediastinum in a Young Adult: A Rare Presentation

Spontaneous pneumomediastinum (SPM) refers to the presence of air in the mediastinum without any obvious cause. It is an uncommon condition occurring due to alveolar rupture as a result of increased intrathoracic pressure. It is commonly seen in young males, patients with known asthmatic disorders and pulmonary diseases. We report a rare case of SPM in a young healthy male without any significant past history. The patient was managed conservatively and discharged.

A Young Healthy Male with Spontaneous Subcutaneous Emphysema Occurring in Neck, Retropharyngeal and Mediastinal Spaces

We present a case of spontaneous cervical, retropharyngeal, and mediastinal emphysema occurring in a previously healthy young male, which is the first described case in Saudi Arabia. The patient was admitted to the ward for observation, monitoring of vital signs, analgesia, and prophylactic antibiotics. The patient was kept under observation for 8 days. During that time, neck pain improved gradually with no episodes of oxygen desaturation or vital sign deterioration. The patient was later discharged with very mild persistent pain. Two weeks after discharge, patient was seen in outpatient clinic and was free of symptoms. Spontaneous subcutaneous emphysema remains a rare presentation encountered in emergency department. The investigations and treatment required for such patients has no consensus between authors. Although most of the reported cases described an uncomplicated course, there is a need for clear guidelines on management protocol.

Analysing the Clinical Features of Pneumomediastinum Associated with Diabetic Ketoacidosis in 79 Cases

OBJECTIVE

To analyse the clinical features of pneumomediastinum associated with DKA (diabetic ketoacidosis) to improve clinicians' understanding of the disease.

METHODS

A total of 78 patients with pneumomediastinum associated with DKA were identified in the literature search, and one patient treated in our hospital was included. The clinical features of the 79 patients were retrospectively analysed, and the pathogenesis, clinical symptoms, diagnostic methods, treatment strategies and prognoses were explored.

RESULTS

All cases were confirmed by chest CT (computed tomography), and Kussmaul respiration, severe vomiting, chest pain were common symptoms. The main treatment principle was to correct acidosis and treat the primary disease. The majority of patients recovered within 1-2 weeks, and only 2 patients died.

CONCLUSION

Pneumomediastinum associated with DKA is a rare disease, and it has a benign course when an early diagnosis is made and aetiological treatment is administered.

Spontaneous Pneumomediastinum Secondary to Hookah Smoking

Patient: Male, 22

Final Diagnosis: Spontaneous pneumomediastinum

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: None

Specialty: Surgery

Spontaneous Pneumomediastinum in a Healthy Young Male: A Case Report from Riyadh, Saudi Arabia

Pneumomediastinum is defined as the presence of air in the mediastinum. Trauma to the nearby organs can cause air to escape into surrounding tissues that may manifest clinically as severe chest pain, voice change, or shortness of breath. However, pneumomediastinum can present spontaneously in healthy individuals with no inciting factors in which case the condition is termed spontaneous pneumomediastinum (SPM). Pneumomediastinum can be challenging to manage due to the absence of clear guidelines for the diagnosis and management.

We present the case of a 21-year-old with no previous medical history who presented with chest pain that was aggravated by speech and breath. The pain was of sudden onset preceded by smoking at 2:00 am. The patient was tachycardic, tachypnoeic with crepitation on palpation and a crunch sound (Hamman’s sign) on auscultation. The patient rated the pain as 5/10 on a 11-point numerical pain rating scale, which then evolved to 10/10. The patient did not have fever, loss of consciousness (LOC), diaphoresis, history of trauma, or previous similar presentation. There were no other associated symptoms. A chest X-ray (posteroanterior (PA) and lateral view) showed pneumomediastinum, but laboratory tests results were otherwise normal. The patient was observed in the emergency room overnight. He remained stable, his tachycardia settled, and there was no leukocytosis or desaturation; however, tachypnea was observed. His pain symptoms were treated with analgesia as needed and the patient was discharged home in a stable condition, to be followed on an outpatient basis.

Spontaneous pneumomediastinum can be challenging to manage due to the lack of reliable incidence data as well as the absence of clear management guidelines. Further research will aid in understanding the true incidence of SPM in Saudi Arabia and help in establishing a consensual approach and treatment guidelines to deal with SPM in otherwise healthy individuals. To the best of our knowledge, this is the first case of SPM in a young male reported from a tertiary hospital in Riyadh, Saudi Arabia.

[Spontaneous pneumomediastinum: about 18 cases]

Le pneumomédiastin spontané se définit par la présence d'air au niveau du médiastin en l'absence de cause traumatique ou iatrogène. Son diagnostic repose sur la radiographie thoracique. Le recours à d'autres examens paracliniques, tels que la tomodensitométrie thoracique ou la fibroscopie bronchique ou digestive, s'impose parfois. L'évolution est le plus souvent favorable. Nous rapportons 18 cas de pneumomédiastin spontané, colligés au service des maladies respiratoires du CHU Ibn Rochd de Casablanca entre 2006 et 2017. Il s'agit de 13 hommes et de cinq femmes dont la moyenne d'âge était de 24 ans. La symptomatologie clinique était dominée par la douleur thoracique rétrosternale. Les circonstances de survenue du pneumomédiastin étaient des quintes de toux dans sept cas, une crise d'asthme dans cinq cas, une consommation de narguilé et des vomissements Itératifs dans deux cas chacun, un accouchement et une exacerbation d'origine bactérienne de BPCO dans un cas chacun. L'évolution était favorable dans tous les cas avec une résorption spontanée du pneumomédiastin. Aucune récidive n'est survenue après un recul moyen de 3 ans.

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.

Diagnosis and treatment of spontaneous pneumomediastinum: experience at a single institution for 10 years

OBJECTIVE

The aim of this study was to identify appropriate method of diagnosis and treatment of spontaneous pneumomediastinum (SPM) based on our experience.

METHODS

The medical records of patients who were diagnosed with SPM and treated at our hospital between April 2006 and July 2015 were, retrospectively, analyzed. The data included characteristics of the patients, method of diagnosis, treatment and clinical course.

RESULTS

Forty-five patients were diagnosed with SPM and treated at our hospital. The mean age of patients was 18.96 ± 4.65 years and 35 patients were male. The main symptoms expressed by these patients were chest pain, throat pain or discomfort, and dyspnea. Nine patients had a precipitating event leading to SPM. Twelve patients had normal chest X-ray findings but were subsequently diagnosed with SPM on chest computed tomography (CT). Additional procedures including esophagogram (n = 36), bronchoscopy (n = 14) and endoscopy (n = 1) were done but none of patients were found to have organ damage. All patients received oxygen inhalation therapy. Oral intake was restricted in 36 patients and 43 patients received prophylactic antibiotics. The mean time taken for symptomatic improvement was 1.73 ± 0.85 days from diagnosis. The mean hospital stay was 3.93 ± 1.44 days and no patient developed recurrence of SPM during the follow-up period.

CONCLUSIONS

In addition to chest X-ray, chest CT is recommended for accurate diagnosis of SPM. However, further invasive investigations, restriction of oral intake and the use of prophylactic antibiotics have minimal role in the diagnosis and treatment of SPM.

Analysis of Patients with Spontaneous Pneumomediastinum

OBJECTIVES

Spontaneous pneumomediastinum is characterized by the presence of air in the mediastinum without any reason. The objective of this study is to report our experience in the diagnosis and treatment of this clinical condition.

MATERIAL AND METHODS

21 patients with spontaneous pneumomediastinum who were referred to our clinic between January 2010 and May 2015 were evaluated retrospectively. The presence of radiological pneumomediastinum and the absence a traumatic cause were taken as the basic criterion.

RESULTS

The mean age of the patients was 24.78 ± 4.37 years. Thirteen patients were male, eight patients were female. The main complaints of the patients were chest pain, dyspnea, neck pain, sore throat and cough. Thirteen patients were smokers. Seven patients had a prior history of asthma, five patient had chronic bronchitis and one patient had cronic obstructive lung diseases. No precipitating factor was identified in 9 patients. While initial complaints was associated with physical effort in 7 patients, three patients cough and two patients had a history of severe crying. Pneumomediastinum was diagnosed by chest radiography in 8 patients, and with chest CT in 13 patients. All the patients were performed bronchoscopy and radiograph of esophagus. Electrocardiogram was taken for all patients. Arrhythmia was detected in 4 of the patients. Treatment included analgesia, rest and oxygen therapy. Mortalitiy and morbidity were not seen. The mean length of hospital stay was 4.4 ± 2.17 days.

CONCLUSION

Spontaneous pneumomediastinum is a benign process. Despite its low incidence, it should be considered in the differential diagnosis of acute chest pain.

Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment

BACKGROUND

Spontaneous pneumomediastinum (SPM) is a benign disease with a variety degree of severity but definite treatment modality is not clearly identified with its rarity. The purpose of this study was to review our experience and discuss the management of SPM according to the severity of disease.

METHODS

From March 1996 to December 2012, total 64 patients were enrolled and classified as mild, moderate and severe groups and subsequent clinical courses were analyzed retrospectively.

RESULTS

Fifty-one were males and 13 were females (M:F =3.9:1) with a mean age of 18 years old (range: 10-30 years old). Thirty-six patients were in mild, 22 in moderate and 6 in severe group. Chief complaints were chest pain (50 cases; 78.1%), neck pain (35 cases; 54.7%), dyspnea (18 cases; 28.1%), odynophagia (9 cases; 14.1%) and precipitating factors were coughing in 12 cases, feeding problems in 9 cases, and vomiting in 7 cases; however, 34 patients (53.1%) had no precipitating signs. All patients received oxygen therapy (100%), prophylactic antibiotics in 57 patients (89.1%), and pain medications in 47 patients (73.4%). The mean hospital stay was 4.6 days (range: 1-10 days). There was an increased linear trend according to time to visit (P=0.023) but clinical course demonstrated no significant trend between groups.

CONCLUSIONS

These data demonstrated that there was no difference in symptom, clinical course and SPM was adequately treated with conservative management regardless of the degree of severity of SPM.

Dyspnoea and chest pain as the presenting symptoms of pneumomediastinum: two cases and a review of the literature

Pneumomediastinum is the presence of air in the mediastinum. It may occur as spontaneous, traumatic, or iatrogenic pneumomediastinum. Although spontaneous pneumomediastinum is usually observed in healthy young men, traumatic pneumomediastinum may be caused by blunt or penetrating trauma to the chest and neck. Pneumomediastinum is a clinical condition with potential complications that cause high morbidity and mortality rates. Pneumomediastinum also may develop without tracheal or oesophageal injury after spontaneous or blunt chest, neck and facial injuries, and it may be accompanied by pneumothorax. We treated two patients who had pneumomediastinum. Case 1 was a 20-year-old man who had pain and dyspnoea around the sternum for one hour, as a result of a blow from an elbow during a football match. Case 2 was a 23-year-old man who had a two-day history of dyspnoea and chest pain with no history of trauma. In both patients, diagnosis of pneumomediastinum was confirmed with thoracic computed tomography scans, and the condition resolved within five days of in-patient observation. In conclusion, the diagnosis of pneumomediastinum should be considered for all patients who present to the emergency department with chest pain and dyspnoea.

Is primary spontaneous pneumomediastinum a truly benign entity?

OBJECTIVE

This study aimed to investigate the benignancy of primary spontaneous pneumomediastinum (PSP), and to establish an appropriate management strategy.

METHODS

Patients diagnosed with PSP between January 2003 and December 2013 were analysed retrospectively. From January 2013 onwards, a simplified protocol, with consensus for the management of PSP, was applied in our hospital.

RESULTS

In total, 37 patients were identified as having PSP during the study period. Among them, 27 were enrolled prior to applying the new protocol. Among these patients, extra diagnostic tests, in addition to chest radiography (CXR) and chest computed tomography (CT), were performed in 15 patients (55.5%). In the pre-protocol decade, a total of 15 patients (55.5%) were initially fasted and 16 (59.3%) were administered antibiotics. Mean hospital stay was 2.9 days (range, 0-5 days). No patient developed complications during the hospital stay and outpatient follow up. Since the revised protocol was in practical use, 10 consecutive patients with PSP were enrolled and reviewed. No additional diagnostic imaging studies or procedures (except for CXR and chest CT) were performed in these patients; furthermore, diet was not restricted and prophylactic antibiotics were not prescribed. Mean hospital stay was 14.5 h (range, 1-34 h). No complications were observed in any of the patients.

CONCLUSIONS

Our management protocol (i.e. routine check of chest CT without any additional diagnostic tests, no special treatment, and early discharge with short-term follow up) may be safe and feasible for the treatment of PSP.

Spontaneous pneumomediastinum: an extensive workup is not required

BACKGROUND

Spontaneous pneumomediastinum is a rare entity usually caused by alveolar rupture and air tracking along the tracheobronchial tree. Despite its benign nature, an extensive workup is often undertaken to exclude hollow viscus perforation. We sought to review our experience with this condition and examine the optimal management strategy.

STUDY DESIGN

We conducted a retrospective review of all radiographic pneumomediastinum cases at a tertiary hospital between 2006 and 2011. The main outcomes measures included length of hospital stay, mortality, and need for investigative procedures.

RESULTS

Forty-nine patients with spontaneous pneumomediastinum were identified, including 26 male patients (53%). Mean age was 19 ± 9 years. Chest pain was the most common presenting symptom (65%), followed by dyspnea (51%). Forceful coughing (29%) or vomiting (16%) were the most common eliciting factors, and no precipitating event was identified in 41% of patients. Computed tomography was performed in 38 patients (78%) and showed a pneumomediastinum that was not seen on chest x-ray in 9 patients. Esophagography was performed in 17 patients (35%) and was invariably negative for a leak. Thirty-eight patients (78%) were hospitalized for a mean of 1.8 ± 2.6 days. No mortality was recorded. Compared with patients who presented with pneumomediastinum secondary to esophageal perforation, spontaneous pneumomediastinum patients were younger, had a lower white cell count, and were less likely to have a pleural effusion.

CONCLUSIONS

Spontaneous pneumomediastinum is a benign entity and rarely correlates with true esophageal perforation. Additional investigation with esophagography or other invasive procedures should be performed selectively with the aim of expediting the patient's care. The prognosis is excellent with conservative management and the risk for recurrence is low.

Pneumomediastinum: etiology and a guide to diagnosis and treatment

BACKGROUND

Pneumomediastinum may be associated with mediastinal organ injury. The aim of this study was to identify predictive factors of mediastinal organ injury in patients with pneumomediastinum to guide diagnosis and treatment.

METHODS

A retrospective review was conducted including patients aged ≥18 years with Current Procedural Terminology code 518.1 (interstitial emphysema) from 2005-2011.

RESULTS

There were 279 of 343 patients (81%) with and 64 of 343 (19%) without history of trauma. In the trauma population, 13 patients (5%) were found to have mediastinal organ injuries, 10 (4%) had airway injuries, and 3 (1%) had esophageal injuries. In the nontrauma population, 36 patients (56%) had spontaneous pneumomediastinum, esophageal injuries were seen in 17 (27%), pneumothorax in 9 (14%), and airway injuries in 2 (3%). The predictors of esophageal injury were instrumentation (odds ratio [OR], 45.7; P < .0001), pleural effusion (OR, 10.5; P < .0001), and vomiting (OR, 9.3; P < .0001). Previous instrumentation was the most significant predictor of airway injury (OR, 9.05; P < .02).

CONCLUSIONS

Mediastinal organ injury in patients with pneumomediastinum is uncommon. Patients presenting with pneumomediastinum without a history of instrumentation, pleural effusion, or vomiting most commonly do not have mediastinal organ injuries.

Systematic review of spontaneous pneumomediastinum: a survey of 22 years' data

OBJECTIVE

To describe and clarify management protocols in relation to spontaneous pneumomediastinum, and try to integrate criteria on this subject.

BACKGROUND

Thoracic physicians are faced with patients who present with gas in the mediastinum, frequently without an obvious etiologic factor. Published material contains heterogeneous information from which different conclusions can be drawn.

METHODS

In a Medline search from 1990 to 2012, we collected data on mortality, morbidity, signs, symptoms, etiologic factors, and diagnostic methods. Standardized mean differences were calculated.

RESULTS

We identified 600 patients in 27 papers with series of >5 patients without precipitating or etiologic factors previous to the clinical presentation, but athletic activity, drug abuse, and history of asthma played an apparent role in the disease process. Most patients complained of thoracic pain and dyspnea, with subcutaneous emphysema and Hamman's sign. The most common complication was tension pneumothorax. Morbidity was seen in 2.8%; no mortality has been reported so far.

CONCLUSION

Spontaneous pneumomediastinum is a rare disease with a benign course, which should be treated conservatively unless a complication mandates an invasive procedure. An algorithm for diagnosis and treatment is offered, based on the available evidence.

Diagnosis and treatment of patients with spontaneous pneumomediastinum

BACKGROUND

Although many patients complaining of chest pain visit the emergency department, very few are diagnosed with spontaneous pneumomediastinum (SPM). We present the management of 20 patients with SPM.

METHODS

We retrospectively analyzed the clinical features, past history, chest X-rays (CXRs), 64-slice helical computed tomography (CT) images, and clinical course of 20 patients with SPM (19 men and 1 woman) who visited the emergency department of the Tokyo Metropolitan Bokutoh Hospital between 2005 and 2010.

RESULTS

SPM predominantly resulted from physical exertion during such activities as sports and weight lifting (8 patients). The most common complaint was chest pain (15 patients), followed by dysphagia (10 patients), and dyspnea (8 patients). Subcutaneous emphysema was detected in 9 patients. The mean body mass index of the patients was 20.8±1.4kg/m(2). Although CXR findings of pneumomediastinum were absent in 5 patients, CT showed findings of the Macklin effect in all patients-interstitial gas was observed in the perihilar area in all patients and in the peripheral lung area in 9 patients (45%). Ten patients were hospitalized. The others received ambulatory care in the form of analgesics without antibiotics. All patients fully recovered without complications.

CONCLUSIONS

Our results showed that 64-slice helical CT is more reliable than CXRs for diagnosing SPM. Moreover, some patients with SPM can be treated without hospitalization, thus decreasing medical expenses for these patients.

Multidetector computed tomography of spontaneous versus secondary pneumomediastinum in 89 patients: can multidetector computed tomography be used to reliably distinguish between the 2 entities?

PURPOSE

To analyze the multidetector computed tomography (MDCT) findings of spontaneous pneumomediastinum (PM) to determine whether MDCT can reliably differentiate spontaneous from secondary PM.

MATERIALS AND METHODS

A retrospective clinical and chest MDCT analysis of all patients diagnosed with spontaneous PM over an 8-year period was performed. Radiologic comparison was undertaken with patients diagnosed with secondary PM from a central airways defect, esophageal rupture, or recent intervention in the airway or esophagus. The Fisher exact test for independence was used to compare the different MDCT findings between the groups.

RESULTS

A total of 89 patients were analyzed, with 1 secondary PM patient being included in both esophageal and central airways subsets, as the patient had an esophageal balloon-assisted intubation. Thirty-four patients were diagnosed with spontaneous PM. Compared with 28 patients with secondary PM from esophageal pathology, spontaneous PM patients were more likely to have air in the anterior mediastinum (97% vs 61%, P<0.001) and pulmonary interstitial emphysema (57% vs 4%, P<0.001), and less likely to show subdiaphragmatic air (0% vs 32%, P<0.001), pleural effusions (9% vs 61%, P<0.001), and acute pulmonary airspace opacities (14% vs 50%, P=0.003). Similarly, compared with 28 patients with secondary PM from trachea and bronchi pathology, patients with spontaneous PM were more likely to have pulmonary interstitial emphysema (57% vs 25%, P=0.01), and were less likely to show subdiaphragmatic air (0% vs 25%, P=0.002), pleural effusions (9% vs 39%, P=0.005), and acute pulmonary airspace opacities (14% vs 43%, P=0.02).

CONCLUSION

Spontaneous PM is associated with a favorable clinical course, and it is possible to suggest this clinical diagnosis based on typical MDCT findings and clinical presentation.

Head and neck manifestations of spontaneous pneumomediastinum

OBJECTIVE

Spontaneous pneumomediastinum (SPM) is a rare disease entity that often manifests localized signs in the head and neck region. The thoracic features of SPM have been well described; however, there is a paucity of information on its otolaryngological characteristics. The authors describe the clinical management among SPM patients having primarily head and neck symptoms.

STUDY DESIGN

Case series with chart review.

SETTING

Cathay General Hospital, Taiwan.

RESULTS

The study included 13 men and 1 woman, with a mean age of 18.8 years (range, 14-29 years). The primary initial symptoms were neck swelling (11), neck pain (10), and odynophagia (9). Neck soft tissue and chest radiography was diagnostic of SPM in all patients. Conservative treatment consisted of bed rest and analgesics, which led to rapid resolution of SPM.

CONCLUSIONS

SPM is a benign entity that responds well to conservative treatment. The results of our investigation highlight the importance of an ear, nose, and throat (ENT) clinical examination as a guide for diagnosing SPM because of the high percentage of ENT manifestations in the initial clinical profiles. Secondary causes of SPM must be ruled out to avoid an unfavorable outcome.

Typical bronchial carcinoid tumour presenting as pneumomediastinum

The authors present a case of a 44-year-old man who presented with acute onset shortness of breath. He had severe subcutaneous emphysema and his chest x-ray and CT scan confirmed presence of air in mediastinum. Rigid bronchoscopy revealed a bronchial tumour which was proven to be a carcinoid on histology. Patient recovered following the surgical excision of the tumour.

[Management of spontaneous pneumomediastinum in the adult: 14 cases and a review of the literature]

The authors report a series of 14 patients hospitalized for spontaneous pneumomediastinium between 1992 and 2006. They included 10 men and four women with an average age of 27.84 years. Dyspnoea dominated the symptoms. The pneumomediastinum was idiopathic in five patients and secondary in the other nine patients, involving an attack of severe asthma in half of the patients, polymyositis in one patient and idiopathic pulmonary fibrosis in one patient, respectively. The patients presenting polymyositis and pulmonary fibrosis died due to respiratory distress. The other patients benefited from asthma treatment or thoracic drainage, and were kept at rest. Their outcome was good. No cases of relapse were observed after an average follow up of 2.11 years.

Spontaneous pneumomediastinum associated with sex

We present a case of spontaneous pneumomediastinum (SPM) associated with sex. A 22-year-old lesbian with a history of asthma, cigarette and illicit drug smoking was diagnosed with a SPM after developing chest pain and dyspnoea in the context of performing oral sex. The main finding was subcutaneous emphysema involving the neck. SPM is an important differential diagnosis for chest pain in young people. It is a benign condition and diagnosis mainly limited to chest X-ray with increased incidence in asthmatics, smokers and drug addicts.

Spontaneous pneumomediastinum: a rare complication of bronchial asthma

Pneumomediastinum is a rare complication of an acute exacerbation of asthma. We describe a 28-year-old female who was admitted to hospital with acute severe exacerbation of asthma and developed a spontaneous pneumomediastinum (SPM) with associated subcutaneous emphysema. She was successfully managed conservatively. On follow up there was resolution of the subcutaneous emphysema and the pneumomediastinum, clinically and radiologically. SPM although usually a self-limiting condition, can occasionally be life threatening. Therefore, it is important to raise the awareness of this potential complication of asthma.

Spontaneous pneumomediastinum: an algorithm for diagnosis and management

Spontaneous pneumomediastinum (SPM) is a rare disorder most often affecting young males which is generally self-limiting. Despite the benign prognosis with few complications and little morbidity, it frequently confuses clinicians in primary settings, who may have difficulty differentiating SPM from other serious organ ruptures, especially oesophageal rupture (the so-called Boerhaave syndrome), which may lead to mediastinitis and may be fatal, even with appropriate interventions. An overview of adult SPM is provided, reviewing 17 studies (414 patients), including our clinical experience, and finally an algorithm for diagnosis and management of SPM is proposed, based on the characteristics of SPM.

Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients

OBJECTIVE

To clarify the clinical presentation and course of patients with spontaneous pneumomediastinum (SP) and to determine the usefulness of diagnostic testing in these patients.

PATIENTS AND METHODS

We conducted a retrospective review of 62 consecutive adult patients (age >or=18 years) diagnosed as having SP during an 11-year period from July 1, 1997, to June 30, 2008. The study cohort included 41 men and 21 women (median age, 30 years; interquartile range, 20-69 years).

RESULTS

Among the 62 study patients, the most common presenting symptoms were chest pain (39 patients [63%]), cough (28 [45%]), and dyspnea (27 [44%]). Preexisting lung diseases were identified in 27 patients (44%) and included interstitial lung disease, asthma, lung malignancies, bronchiolitis obliterans syndrome, chronic obstructive pulmonary disease, bronchiectasis, and cystic lung lesions. The initial diagnosis of SP was achieved by chest radiography in 52 patients (84%); the remaining cases were diagnosed by computed tomography. Forty-seven patients (76%) were hospitalized for a median duration of 2.5 days. Additional diagnostic procedures were performed in 27 patients (44%) and included contrast esophagography, bronchoscopy, and esophagogastroduodenoscopy; however, they did not yield a pathologic cause in any patient. Pneumothorax was identified in 20 patients (32%), but less than one-third of these patients underwent chest tube thoracostomy. No episodes of mediastinitis or sepsis occurred. Recurrence of SP was seen in 1 patient, and thoracoscopic surgery was performed in 1 patient for persistent air leak (pneumothorax).

CONCLUSION

Spontaneous pneumomediastinum was associated with a relatively benign clinical course; however, pneumothorax was seen in 32% of cases. Diagnostic testing to determine a pathologic cause yielded little clinically relevant information in these patients.

[Spontaneous pneumomediastinum: asthma]

Pneumomediastinum is defined as the presence of free air in the mediastinum, and the spontaneous occurs in the absence of diseases or precipitating factors. It is rare in adults, and it is more frequent in newborns. However, it occurs more in young adults, with an 8:1 relationship between men and women. It constitutes a rare finding in asthma, representing 1% of the cases. More frequent symptoms are chest pain and dyspnea. Diagnosis is made with image examinations, such as radiography and chest computed tomography. Treatment of choice is conservative, nonoperative, with a favourable prognosis in the majority of the cases. Our aim is to report a case of this pathology in a young adult seen in our service with chest pain and dyspnea. He underwent complementary examinations and the diagnosis was spontaneous pneumo- mediastinum. This patient was submitted to a conservative treatment with excellent clinical evolution. At the moment, he is asymptomatic and under routine clinical care.

Management of spontaneous pneumomediastinum based on clinical experience of 25 cases

STUDY OBJECTIVES

Spontaneous pneumomediastinum (SPM) is a rare disorder that usually occurs in young individuals and has a self-limiting course and no recurrence in most cases. But actually in many cases, patients are undergo some examinations or some limitations. The purpose of this study was to evaluate the clinical characteristics and recommend appropriate management of SPM.

DESIGN

Retrospective research of clinical records of a single institution.

RESULTS

Over 11 years, we diagnosed 25 patients (18 males) with SPM. Their average age was 20.1 years (range 13-28 years). Chest pain or neck symptoms were most frequent, and 17 patients (68%) had subcutaneous emphysema. In all cases, blood counts and C-reactive protein (CRP) were measured, and their mean values were 10,100+/-4600/mm(3) and 1.0+/-1.5 mg/dL, respectively. In 20 patients (80%), either leucocytosis or elevated CRP was observed. Twenty-four patients (96%) were admitted (average 7.8+/-4.1 days) and 20 of them were prescribed antibiotics or limited oral intake. The symptoms were self-limiting in all cases and disappeared on average 1.8+/-0.9 days after diagnosis. No recurrence was noted in the approximately 2 years follow-up period.

CONCLUSION

SPM is a self-limiting disease with mild inflammatory signs. For patients suspicious of SPM, shortened hospitalization for about 2 days with observation alone may be feasible, if their symptoms improve gradually. Otherwise, less invasive procedures, such as esophagram, should be performed immediately. Long-term follow-up is usually unnecessary. We propose a new algorithm for management of SPM based on clinical experience.

Two case reports of pneumomediastinum

BACKGROUND

We present two cases of pneumomediastinum in patients who presented to the accident and emergency department of a large teaching hospital. One case had a history of inhalational drug abuse, which may have contributed to the event, while the other had no obvious precipitating factors.

AIMS

To evaluate the presenting symptoms, physical signs, diagnosis and management of pneumomediastinum with a review of the literature.

METHODS

We describe two cases of pneumomediastinum with a literature review.

CONCLUSIONS

Pneumomediastinum is an uncommon entity, first described almost 400 years ago. It presents with relatively non-specific symptoms and signs and will require radiological investigations to clarify the diagnosis. Treatment is conservative but will require close observation for the development of complications and occult visceral perforation. Complete resolution can be expected.

Spontaneous pneumomediastinum: experience in 18 adult patients

Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 +/- 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (+/-1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.

Cervical complications following routine tonsillectomy and adenoidectomy

PURPOSE OF REVIEW

Fortunately, patients undergoing adenotonsillectomies have far more complaints than complications. Sore throats, dysphagia, and neck pain are frequent and expected symptoms after surgery. Differentiating these symptoms from early signs of severe cervical complications can be difficult. Such complications are rare but include atlanto-axial subluxation (Grisel's syndrome), cervical necrotizing fasciitis, cervical emphysema and cervical oseteomyelitis. Due to the frequency with which adenotonsillectomies are performed, most otolaryngologists will encounter these events during their career. This article is thereby intended to elucidate the early warnings, appropriate diagnostic workup, and therapeutic modalities for cervical complications following adenotonsillectomies.

RECENT FINDINGS

Early recognition and intervention can prevent devastating morbidity and mortality described with cervical complications. Computed tomography scanning remains the gold standard for diagnosing cervical complications after adenotonsillectomy. Although a range of severity exists in cervical complications, most cases can be managed conservatively with broad spectrum antibiotics, observation, bedrest and immobilization in cases of Grisel's syndrome. Cervical necrotizing fasciitis requires a high index of suspicion and urgent management to avoid fatal consequences.

SUMMARY

This is a review of the most frequently encountered, although rare, cervical complications following adenotonsillectomies. It gives the reader an insight into the efficient diagnosis and management of these complications.

Spontaneous pneumomediastinum due to achalasia: a case report

Spontaneous pneumomediastinum (SPM) is a rare and benign clinical entity characterized by free air around mediastinal structures. Precipitating factors include violent cough, asthma, inhalational drugs, labor and exercise. We report a case of SPM due to achalasia which to the best of our knowledge, has never been reported. In achalasia, Valsalva maneuver might accompany severe vomiting. This causes alveolar rupture due to elevated intrabronchial and intra-alveolar pressure. Air tracks along the mediastinal spaces cause SPM. In our patient, there was no evidence of esophageal perforation. Tension pneumomediastinum and pneumothorax are complications of SPM.