Is primary spontaneous pneumomediastinum a truly benign entity?

Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male (n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology.

Pneumomediastinum and pneumopericardium 11 days after Whipple procedure. A case report and review if the literature

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Spontaneous Pneumomediastinum is a rare disease.

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Combination with Pneumopericardium has not been reported yet.

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There are no clear guidelines for diagnosis and treatment.

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Conservative treatment with close monitoring is most of the times sufficient.

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In surgical patients an upgraded diagnostic and treatment plan could be necessary.

Introduction

Spontaneous pneumomediastinum (SPM) is a rare condition classified as free air in the mediastinum in the absence of any precipitating cause. This is the first time that a synchronous presence of pneumopericardium is described. To date, there are no clear guidelines for diagnosis and treatment.

Presentation of a case

A 34-year old Caucasian male patient presented to our institution with a recently diagnosed pancreatic adenocarcinoma. He underwent an uneventful pancreaticoduodenectomy (Whipple procedure). Preoperative and intraoperative chest X-Ray after a central line placement were normal. The postoperative course was uneventful, but few hours before his discharge he presented an acute tachycardia and tachypnea with hypocapnia and a transient loss of consciousness. The full-body CT scan revealed a pneumomediastinum and pneumopericardium without any findings of anastomotic leak or other pathology from the abdomen. A meticulous review of the literature was conducted about the pathophysiology, treatment options and outcomes of pneumomediastinum after a surgical procedure.

Discussion

This is the first study presenting the case of spontaneous pneumomediastinum with a synchronous pneumopericardium in the literature as a late complication of Whipple procedure. The applied diagnostic algorithm and conservative treatment are presented to extend our limited knowledge about this rare medical entity.

Conclusion

Awareness of these medical entities is important for the adequate management and optimal outcome of patients presenting a spontaneous pneumomediastinum. As such, all cases, treatment decisions and outcomes should be reported.

The implications of pneumomediastinum and subcutaneous emphysema for the paediatric otolaryngologist

Three patients presented within a 6-month period with pneumomediastinum. The underlying cause in each was distinct. One case occurred due to blunt laryngeal trauma and required urgent surgical intervention due to a decompensating airway. The second case was related to tracheal perforation secondary to a myofibroblastic tracheal tumour and the final case was related to adenovirus upper respiratory tract infection. Pneumomediastinum may be spontaneous or secondary to an underlying cause. Children should be managed using a multidisciplinary approach. Investigation and management should be influenced by clinical stability and invasive procedures should only be considered in patients who exhibit respiratory distress.

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.