[Thyroid cartilage fracture following sneezing as a cause of spontaneous pneumomediastinum]

OBJECTIVE

To evaluate the possible etiological factors of spontaneous pneumomediastinum and to describe a case that was unusual in its etiology: a thyroid cartilage fracture as a result of sneezing.

MATERIAL AND METHODS

Six patients (four male, two female, aged 16-82 years) were hospitalized with spontaneous pneumomediastinum diagnosed with a chest X-ray in five patients and 100% with computed tomography. Treatment was symptomatic.

RESULTS

The commonest symptoms (cough, shortness of breath, hoarseness) were in four patients. Spontaneous pneumomediastinum developed in three cases as a result of bronchospasm during an attack of bronchial asthma, in one patient after exercise, in one after fibrogastroscopy, in one after sneezing. We report a 30-year-old man who presenting subcutaneous emphysema on the neck, hoarseness, pain when swallowing, hemoptysis developed after sneezing. His computed tomography revealed a pneumomediastinum due to fistula of the fracture of the thyroid cartilage following sneezing while simultaneously obstructing both nostrils. At laryngoscopy, there was a linear hematoma in the resolution stage on the anterior wall of the larynx. He was treated conservatively and recovered rapidly. There are no previous published reports of spontaneous pneumomediastinum following fracture of the thyroid cartilage.

CONCLUSION

Fracture of the thyroid cartilage as a result of a sharp rapid increase in airway pressure during a sneeze with blocked nasal passages can be one of the rare causes of spontaneous pneumomediastinum. Avoid closing both nostrils at the same time when sneezing.

Spontaneous pneumomediastinum - Hamman´s syndrome

This case study presents a rare case of a 29-year-old woman with spontaneous pneumomediastinum who was treated in the emergency department for subjective dyspnea, rhinitis, and a subjectively reported increasing swelling of the throat. The clinical presentation was only characterized by crepitus in the neck and supraclavicular areas. CT scan of the neck and chest revealed massive emphysema of the soft tissues of the neck, chest, the right side of the face, and pneumomediastinum extending to the diaphragm. Based on the clinical presentation and imaging findings, which were consulted with thoracic surgeons, we assessed the condition as benign spontaneous pneumomediastinum. The patient was treated conservatively and discharged from the hospital on the third day of hospitalization with the need of aftercare.

Spontaneous Pneumomediastinum in a Middle-Aged Female Patient With Schizophrenia: A Case Report

A middle-aged female patient with schizophrenia and osteoporosis presented to the emergency department with complaints of sore throat, neck pain, and dysphagia, which was identified as spontaneous pneumomediastinum (SPM) on chest CT. SPM has been reported in anorexia nervosa, but this is the first report of SPM in schizophrenia. In anorexia nervosa, an increase in intrathoracic pressure because of vomiting can cause positive pressure SPM, but this patient was considered to have negative pressure SPM because of decreased mediastinal pressure. In schizophrenia patients with unexplained chest pain, neck pain, and dysphagia, SPM should be considered a differential disease, and a chest CT scan is useful for diagnosis.

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.

Pneumorrhachis with spontaneous pneumomediastinum in pediatric patients: An 11-year retrospective study in Southern Taiwan

BACKGROUND

Although uncommon, available evidence suggests that pneumorrhachis (PR) with spontaneous pneumomediastinum (SPM) in adulthood is usually benign and self-limiting. This study aimed to review our experience and identify the risk factors of PR in pediatric patients with SPM.

METHODS

Between September 2007 and September 2017, SPM in patients aged ≤18 years was retrospectively reviewed and clinical features and outcomes between SPM patients with and without PR were analyzed.

RESULTS

In total, thirty consecutive occurrences of SPM in 29 patients were finally identified and classified into SPM (n = 24) and SPM plus PR (n = 6) groups. No significant differences in received interventional exams, prophylactic antibiotic administration or restriction of oral intake between the two groups were found. Both groups were treated with hospitalization predominantly; but the SPM plus PR group tended to have longer length of hospital stay (median 5.5 vs. 3 days, p = 0.08). PR was observed more frequently in patients with abnormal serum C-reactive protein (CRP) levels (>5 mg/L), identified predisposing factors, and those with more severe grade of SPM (p = 0.005, 0.001 and < 0.001, respectively). On multivariable regression analysis, the SPM plus PR group exhibited more predisposing factors than did the SPM group (coefficient: 0.514, standard error: 0.136, p < 0.001). All patients were successfully treated without morbidity and mortality.

CONCLUSION

Although patients with pneumorrhachis retained a higher CRP level, more identified predisposing factors and prolonged inpatient care, conservative management without an extensive work-up would be an appropriate and favorable strategy in pediatrics with concurrent SPM and PR.

A clinical review of spontaneous pneumomediastinum

Primary spontaneous pneumomediastinum is a rare, often benign and self-limited condition defined by air within the mediastinum. However, correctly distinguishing primary spontaneous pneumomediastinum from secondary causes, especially esophageal perforation, remains a diagnostic challenge. There is significant debate regarding the balance of completing a thorough but not overly invasive and costly diagnostic workup. This clinical review aims to gather the limited data regarding spontaneous pneumomediastinum management from case series and retrospective cohort studies, and presents an evaluation algorithm and treatment plan stratified by clinical history. Understanding specifically if the patient presents with coughing versus forceful vomiting is critical to help elucidate the etiology and guide management of pneumomediastinum. Patients who present with forceful vomiting or retching should be considered with higher degree of suspicion for secondary causes of pneumomediastinum, specifically esophageal perforation. However, especially in children, aggressive diagnostic workup is not warranted in every case. After ruling out other etiologies of pneumomediastinum, spontaneous pneumomediastinum can be commonly treated with symptomatic management without the aggressive use of antibiotics or diet restriction. Hospital length of stay may also be minimized on a case-by-case basis. Overall, recurrence of spontaneous pneumomediastinum is rare and outpatient follow up may be safely limited to those at highest risk of recurrence.

Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with COVID-19: Three-Year Debriefing across Five Pandemic Waves

Spontaneous pneumothorax and pneumomediastinum (SP-SPM) are relatively rare medical conditions that can occur with or independently of COVID-19. We conducted a retrospective analysis of SP-SPM cases presented to the emergency departments (EDs) of two University-affiliated tertiary hospitals from 1 March 2020 to 31 October 2022. A total of 190 patients were identified: 52 were COVID-19 cases, and 138 were non-COVID-19 cases. The primary outcome we were looking for was in-hospital mortality. The secondary outcomes concerned the disease severity assessed by (a) days of hospitalization; (b) required mechanical ventilation (MV); and (c) required intensive care (IC). All were investigated in the context of the five pandemic waves and the patients' age and comorbidities. The pandemic waves had no significant effect on the outcomes of these patients. Logistic regression found age (OR = 1.043; 95%CI 1.002-1.085), COVID-19 (OR = 6.032; 95%CI 1.757-20.712), number of comorbidities (OR = 1.772; 95%CI 1.046-3.001), and ground-glass opacities over 50% (OR = 5.694; 95%CI 1.169-27.746) as significant risk predictors of in-hospital death while controlling for gender, smoking, the pandemic wave, and the extension of SP-SPM. The model proved good prediction performance (Nagelkerke R-square = 0.524) and would hold the same significant predictors for MV and IC.

A Case Report of Spontaneous Pneumomediastinum From an Unusual Cause: Baritone Practice

Spontaneous pneumomediastinum (SPM) is a rare but potentially life-threatening clinical entity in which free air is introduced into the mediastinum. It most commonly presents in young males and has an incidence of approximately 0.002% of the general population. Symptoms include sudden onset chest pain, dyspnea, neck pain, vomiting, and odynophagia. Physical examination usually reveals subcutaneous emphysema, hoarse voice, tachycardia, tachypnea, and occasionally a Hamman's sign, which is a mediastinal "crunch" sound heard on cardiac auscultation. We present a case of an 18-year-old male baritone player who presented to the ED with chest pain and odynophagia shortly after waking up one morning. The patient's chest radiograph (CXR) revealed free air in the mediastinum with subcutaneous air tracking into the soft tissues of the neck and supraclavicular region. CT of the chest with contrast esophagram confirmed the diagnosis of primary SPM. The cause of his condition was likely due to barotrauma secondary to playing the baritone in his marching band. He had no evidence of esophageal injury or infectious process which further supports the diagnosis of primary SPM. After an extensive workup, the patient was discharged from the ED with instructions on rest, analgesia, and antitussives as needed. Evaluation of chest pain patients in the ED should include a CXR, in addition to other indicated tests, to rule out this potentially debilitating condition. Fortunately, though SPM is potentially life-threatening, most cases resolve spontaneously without surgical intervention.

Spontaneous Pneumomediastinum: A Rare Cause of Chest Pain

Spontaneous pneumomediastinum is a rare medical condition characterized by the presence of free air in the mediastinum, not preceded by trauma, surgery, or another medical procedure. It predominantly affects young adult males and usually has a benign course, and in most cases, it is not possible to identify the precipitating factor. There are some conditions that predispose to its occurrence, namely those that lead to an increase in intrapleural pressure, such as coughing, vomiting, or vigorous exercise. We report a case of a 21-year-old male who presented with acute-onset shortness of breath after an episode of coughing and was found to have mediastinal and subcutaneous emphysema. Clinical, laboratory, and radiological studies did not demonstrate any predisposing factor, and the case was classified as spontaneous pneumomediastinum.

Acute Airway Compromise Due to Spontaneous Pneumomediastinum in COVID-19 Infection and Subsequent Rapid Formation of Pulmonary Subpleural Bullae: A Case Report

Spontaneous pneumomediastinum (SPM), an increasingly documented complication of COVID-19 infection, usually presents with retrosternal chest pain and dyspnea but can present atypically. In this case, an exceptionally rare presentation could have led to inappropriate management and a poor outcome. Here, a previously healthy 41-year-old Afro-Caribbean male non-smoker presents with acute airway compromise due to SPM. Conservative management proved effective, with anxiolysis to mitigate patient self-induced lung injury (PSILI) and oxygen supplementation via a non-rebreather mask to increase the resolution rate till the patient stabilized over the following days. The sequelae of the lung insult were noted in subsequent imaging, showing the formation of many subpleural bullae. Our case demonstrates the need for a high index of suspicion for pneumomediastinum among teams caring for COVID-19 cases. It also highlights the potential need for follow-up for further research on pulmonary sequelae.

Spontaneous pneumomediastinum and macklin effect: Three rare case reports with computed tomography findings

Spontaneous pneumomediastinum (SPM) is defined as free air or gas in the mediastinum that is not associated with an obvious cause such as chest trauma. The SPM results from acutely elevated intra-alveolar pressure: The high-pressure gradient between the distal alveoli and the pulmonary interstitium leads to alveolar rupture. This causes free gas to separate through the peribronchovascular fascial sheaths (interstitial emphysema) into the hilum and then into the mediastinum. Once the gas is in the mediastinum, it can travel up to the cervical soft tissues (even the retroperitoneum) producing subcutaneous emphysema. The Macklin effect appears on thoracic computed tomography (CT) as linear air collections adjacent to bronchovascular sheaths. This case report presents CT findings of SPM due to the Macklin effect in three cases and a brief literature review on this subject.

[Hamman's syndrome in SARS-CoV-2 pneumonia]

Hamman's syndrome, or spontaneous pneumomediastinum, is the presence of air in the mediastinum without a history of previous pulmonary pathology, chest trauma or iatrogenesis. It has been described as a rare complication in patients with COVID-19 pneumonia. It is postulated that an increase in airway pressure associated with diffuse alveolar damage caused by the virus produces an air leak into the mediastinum. Chest pain and dyspnea associated with subcutaneous emphysema should make the treating physician suspicious. We introduce a 79-year-old patient who, during hospitalization for pneumonia secondary to COVID-19, suddenly developed dyspnea, chest pain, coughing spells and bronchospasm with the discovery of spontaneous pneumomediastinum on chest tomography. He evolved favorably with bronchodilator treatment and temporary oxygen therapy. Hamman's syndrome is a rare cause of respiratory failure progression in patients with COVID-19 pneumonia. Its recognition is crucial to implement the appropriate treatment.

Post-partum Hamman's Syndrome

Hamman's syndrome is an uncommon complication of labor. Its diagnosis is based on clinical suspicion and CT imaging. It is often a benign and self-limiting condition occurring in healthy patients. The risk factors are nulliparity and a prolonged second stage of labor. Hamman's syndrome has life-threatening implications that underscore the importance of early diagnosis and management to avoid any difficulty. This paper discusses the case of a 21-year-old, healthy female without allergies who was admitted to the hospital in spontaneous labor at 40 weeks of gestation. During the second stage of labor, she developed Hamman's syndrome and presented with subcutaneous emphysema, which led to an emergency C-section. After a chest and cervical CT scan that showed extensive subcutaneous emphysema and a pneumomediastinum, the patient was admitted to the ICU.

Pneumomediastinum and Pneumorrhachis Associated With Cannabinoid Hyperemesis Syndrome

More complications continue to be reported with the increasing use of marijuana (MJ) in the United States, including the increasing prevalence of Cannabinoid Hyperemesis Syndrome (CHS). To our knowledge, based on a thorough review of the literature, we present the third case of CHS with associated pneumomediastinum (PM) and the first case of pneumorrhachis (PR) in a young healthy patient. The main objective of this paper is to heighten awareness of CHS and its potential complications. A brief discussion of a focused history is essential for diagnosis, proper evaluation, and treatment.

Massive Spontaneous Pneumomediastinum-A Form of Presentation for Severe COVID-19 Pneumonia

For COVID-19 pneumonia, many manifestations such as fever, dyspnea, dry cough, anosmia and tiredness have been described, but differences have been observed from person to person according to age, pulmonary function, damage and severity. In clinical practice, it has been found that patients with severe forms of infection with COVID-19 develop serious complications, including pneumomediastinum. Although two years have passed since the beginning of the pandemic with the SARS-CoV-2 virus and progress has been made in understanding the pathophysiological mechanisms underlying the COVID-19 infection, there are also unknown factors that contribute to the evolution of the disease and can lead to the emergence some complications. In this case report, we present a patient with COVID-19 infection who developed a massive spontaneous pneumomediastinum and subcutaneous emphysema during hospitalization, with no pre-existing lung pathology and no history of smoking. The patient did not get mechanical ventilation or chest trauma, but the possible cause could be severe alveolar inflammation. The CT results highlighted pneumonia in context with SARS-CoV-2 infection affecting about 50% of the pulmonary area. During hospitalization, lung lesions evolved 80% pulmonary damage associated with pneumomediastinum and subcutaneous emphysema. After three months, the patient completely recovered and the pneumomediastinum fully recovered with the complete disappearance of the lesions. Pneumomediastinum is a severe and rare complication in COVID-19 pneumonia, especially in male patients, without risk factors, and an early diagnosis can increase the chances of survival.

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.

Pneumorrhachis: An uncommon radiological entity

Pneumorrhachis (PR) is a rare and interesting phenomenon, in which air is present within the spinal canal. The aetiologies are varied, broadly grouped as traumatic, non-traumatic or iatrogenic. Pneumorrhachis secondary to spontaneous pneumomediastinum (SPM) and barotrauma of the lungs is uncommon and even rarer within the paediatric group. This report describes a paediatric patient presenting with a persistent cough who developed a SPM and subsequent PR.

Spontaneous Pneumomediastinum: A Possible Severe Condition in SARS-CoV-2 Pneumonia

Background  Spontaneous pneumomediastinum (SP) is the presence of free air into extra-alveolar tissues within the mediastinum, without notion of trauma. This rare condition may occur as a complication of an underlying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. Higher rates of mechanical ventilation are reported in coronavirus disease 2019 (COVID-19) patients with pneumomediastinum.

Case Description  We report two cases of COVID-19 infected patients suffering from mild and severe SP and their outcome.

Discussion  The objective of this report is to review the literature about this condition. We discuss about the pathological pathways underlying this complication and how it reflects the severity of COVID-19 pneumonia.

Conclusion  Currently, it remains unclear if SP in SARS-CoV-2 pneumonia is a potential predictor of disease worsening, for it does not seem to be related with a higher rate of mortality.

Severe Spontaneous Pneumomediastinum in a Girl with Cystic Fibrosis

We report on an 11-year-old girl with cystic fibrosis who presented with thoracic pain and an extensive subcutaneous emphysema and subsequently developed progressive respiratory distress. The chest computed tomography revealed a huge pneumomediastinum. Due to the development of severe respiratory failure, urgent needle thoracocentesis was necessary that resulted in only temporary improvement. Therefore, under general anesthesia two mediastinal drains were introduced. Using active suction, the size of the pneumomediastinum decreased gradually and the drains were removed after 3 weeks. Here, we describe an extremely rare situation, when acute surgical intervention was necessary in a child with spontaneous pneumomediastinum.

Air! Places We Not Ought to See It: Incidentally Detected Spontaneous Pneumomediastinum Complicated by Cervical Emphysema on Positron Emission Tomography/Computed Tomography

Spontaneous pneumomediastinum is a rare condition, characterized by the presence of air in the mediastinum without any apparent precipitating cause. It is mainly a radiological diagnosis. The onus of differentiating between secondary and spontaneous pneumomediastinum lies on a thorough workup. In addition to etiology, complications such as tension pneumomediastinum, cervical emphysema, and pneumorachis. When present, must be diagnosed promptly. Spontaneous pneumomediastinum is a benign condition which is usually managed conservatively. Although not routinely seen on positron emission tomography/computed tomography, when present, they must be picked up and reported accurately to guide appropriate management of the patient.

The first reported use of autologous blood pleurodesis for treatment of prolonged air leak in COVID-19-related spontaneous pneumomediastinum and pneumothorax: A case report

Spontaneous pneumomediastinum (SPM) and pneumothorax (PTX) have been described as rare complications of COVID-19 pneumonia. We present a case of COVID-19 pneumonia which was complicated by SPM on Day 13 of admission with progression to spontaneous PTX 2 days later which necessitated intercostal chest drainage. It was complicated by prolonged air leak (PAL) for the next 9 days despite being on continued low-dose suction and another additional larger bore intercostal drain inserted. Surgical pleurodesis was not an option in view of anaesthesia and operative risk expected in COVID-19. In view of this, autologous blood pleurodesis (ABP) to address the alveolar pleural leak was opted. ABP has been previously used for PAL in cases of non-COVID-19-related intractable spontaneous PTX. The air leak ceased with subsequent lung re-expansion, with good clinical and radiological improvement. He was discharged well after resolution of PTX which required intercostal drain for a total of 15 days.

A Rare Case of Vaping-Induced Spontaneous Pneumomediastinum

Vaping is the process of inhaling an aerosol produced by heating a liquid or wax containing substances such as nicotine, cannabinoids (e.g., tetrahydrocannabinol, cannabidiol), flavoring, and additives (e.g., glycerol, propylene glycol). The presence of air or gas in the mediastinum is pneumomediastinum.

We present a rare case of vaping-induced spontaneous pneumomediastinum. A young 20-year-old female patient with a history of vaping and no past medical history presented with acute chest pain to an emergency room. The urine drug screen was positive for cannabinoids. Imaging studies - chest x-ray and computed tomography of the chest - showed pneumomediastinum. The patient was discharged after a day of observation and counseling to quit vaping.

Spontaneous Pneumomediastinum in a Healthy Pediatric Patient

Spontaneous pneumomediastinum (SPM) is a rare condition, especially in children with no predisposing factors. In the vast majority of patients, this condition is benign and self-limiting; however, there is always the possibility that serious and potentially life-threatening complications such as mediastinitis or cardiac tamponade could arise. Early recognition, prompt diagnosis, and appropriate management allow for ideal care and prevent unnecessary and excessive investigations in these patients. An eight-year-old female was admitted to the emergency department with SPM after swimming and no known predisposing lung conditions. The probable causative event was likely to be pressure changes in the alveoli during swimming. This is notable because the patient's SPM occurred in the absence of an underlying cause such as asthma. The patient was admitted overnight for monitoring and pain control. The symptoms resolved the following day, along with a decrease in the size of the SPM on the chest X-ray. Physicians should be aware of the signs of SPM in young patients who present with chest pain in the absence of trauma or pulmonic disease. A review of literature highlighted the pathophysiology and recommended treatment course for similar cases.

Spontaneous Pneumomediastinum in COVID-19 Pneumonia

Spontaneous pneumomediastinum (SPM) is the collection of air within the mediastinal cavity, which is commonly described in the literature for mechanical ventilation and perforation of hollow viscera. Coronavirus disease 2019 (COVID-19) is a rare but salient etiology of this complication in the current pandemic. Here, we are narrating a case of a 46-year-old male, in whom COVID-19 pneumonia was complicated by SPM. The complication was identified on chest computed tomography (CT) and was managed conservatively, leading to a favorable outcome. SPM has undemanding management, but timely identification and appropriate treatment institution are crucial in this milieu. A literature search revealed similar cases of SPM in COVID-19 with different outcomes and the important ones are included in this report.

An isolated spontaneous pneumomediastinum as a rare complication of COVID 19

The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications. This case report illustrates a rare issue : the spontaneous pneumomediastinum. A 73-year-old male presented with chills, and respiratory symptoms. A reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19. At admission, the patient was in severe respiratory distress. C reactive protein was 54 mg/l (normal: 0-5 mg/l), , troponin were negative, brain natriuretic peptid 55 pg/ml (normal range <100 pg/ml) and D-dimer 700 mcg/l (normal: 0-500 mcg/l). Arterial blood gases showed pH 7.49 (normal: 7.35-7.45), PCO2 33,8 mmHg (normal: 34-46 mmHg) and PO2 56 mmHg (normal: 80-97 mmHg) with 16 liter per minute of oxygen. Computed tomography of the chest (CT chest) showed diffuse groundglass opacities (60-70%) without pulmonary embolism. Diagnosis of acute respiratory distress syndrome (ARDS) was made. Low flow oxygen was provided (Oxygen saturation target ≥ 94%), intermediate dose of low molecular weight heparin and 8mg of dexamethason were administarted daily. On day 10, worsening hemodynamics and blood oxygen levels was noted. CT chest showed moderate bilateral pneumomediastinum, without pneumothorax, persistent groundglass opacities (75%) with early fibrosis elements. The patient recovered with no pulmonary sequelae. This case report encourages health workers to get used with infrequent clinical and radiological manifestations of COVID-19 that is still surprising the world.

A case report of pneumomediastinum in a COVID-19 patient treated with high-flow nasal cannula and review of the literature: Is this a "spontaneous" complication?

Oxygen support with high-flow nasal cannula (HFNC) is gentler than mechanical ventilation and may provide significant benefits, but more studies are needed to investigate the efficacy and safety of different respiratory supports in patients with COVID-19 pneumonia.

A case of spontaneous pneumomediastinum in a patient with severe SARS-CoV-2 and a review of the literature

Spontaneous pneumomediastinum is defined as having an etiology that is not related to surgery, trauma, or mechanical ventilation. Precipitating causes of spontaneous pneumomediastinum include coughing, exercise, vomiting, infection, underlying lung diseases such as asthma, and illicit drugs. Symptoms include chest pain, shortness of breath, and dysphagia. A 54-year-old man presented with 2 weeks of shortness of breath, cough, and fever. He was admitted for severe SARS-CoV-2 pneumonia and acute hypoxic respiratory failure requiring non-rebreather mask. Chest imaging on admission showed bilateral peripheral consolidations and pneumomediastinum with subcutaneous emphysema. No precipitating event was identified. He did not require initiation of positive pressure ventilation throughout his admission. On hospital day 7, chest imaging showed resolution of pneumomediastinum and subcutaneous emphysema, and he was successfully discharged on oxygen therapy. Spontaneous pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 infection. Spontaneous pneumomediastinum is typically benign and self-limiting, requiring only supportive treatment.

Frequency and Risk Factors for Spontaneous Pneumomediastinum in COVID-19 Patients

Background: Spontaneous pneumomediastinum (SPM) is an uncommon condition in COVID-19 patients. No information about outcome or risk factors is available at the time. The aim of this research is to report on the frequency and risk factors of spontaneous pneumomediastinum in COVID-19 patients. Materials and Methods: An unmatched case-control study was carried out in a tertiary health-care facility for patients with COVID-19. Electronic files were reviewed to identify patients with confirmed COVID-19 infection by RT-PCR. Univariate analysis was used to describe demographic data. Mean differences were calculated using the Mann-Whitney test. Frequency and odds ratios were calculated by standard operations. Results: A total of 271 patients were included in the study. Nine patients showed spontaneous pneumomediastinum and four of them presented associated spontaneous pneumothorax. The most common risk factors associated with poor outcomes in COVID-19 patients were not considered as risk factors for spontaneous pneumomediastinum development. Conclusion: Spontaneous pneumomediastinum is an uncommon clinical feature in COVID-19 patients. More research is necessary to formulate statements regarding prevalence, risk factors, and outcome.

Spontaneous Pneumomediastinum, Pneumothorax, Pneumopericardium and Subcutaneous Emphysema-Not So Uncommon Complications in Patients with COVID-19 Pulmonary Infection-A Series of Cases

(1) Background: Spontaneous pneumomediastinum (PM), pneumothorax (PT), and pneumopericardium (PP) were recently reported as rare complications in patients with severe COVID-19 pneumonia, and our study aims to follow the evolution of these involvements in 11 cases. The presumed pathophysiological mechanism is air leak due to extensive diffuse alveolar damage followed by alveolar rupture. (2) Methods: We followed the occurrence of PM, PN, PP, and subcutaneous emphysema (SE) in 1648 patients hospitalized during the second outbreak of COVID-19 (October 2020-January 2021) in the main hospital of infectious diseases of our county and recorded their demographic data, laboratory investigations and clinical evolution. (3) Results: Eleven patients (0.66%) developed PM, with eight of them having associated PT, one PP, and seven SE, in the absence of mechanical ventilation. Eight patients (72.72%) died and only three (27.27%) survived. All subjects were nonsmokers, without known pulmonary pathology or risk factors for such complications. (4) Conclusions: pneumomediastinum, pneumothorax, and pneumopericardium are not so uncommon complications of SARS-CoV2 pneumonia, being observed mostly in male patients with severe forms and associated with prolonged hospitalization and poor prognosis. In some cases, with mild forms and reduced pulmonary injury, the outcome is favorable, not requiring surgical procedures, mechanical ventilation, or intensive care stay.

Pediatric Spontaneous Pneumomediastinum after a Push-Up Exercise: An Uncommon Complication of a Common Exercise

Pediatric spontaneous pneumomediastinum is an uncommon condition associated with infection, trauma, or coexisting structural lung pathology. Exercise-related spontaneous subcutaneous emphysema and pneumomediastinum are rarely reported. However, severe pneumomediastinum may coexist with pneumothorax, pneumorrhachis, and subcutaneous emphysema, which can potentially lead to serious complications, including airway obstruction and pneumorrhachis. Therefore, early diagnosis and timely management are important for physicians to determine the etiology and prevent further damage. Here, we present a case of exercise-related spontaneous subcutaneous emphysema and pneumomediastinum to highlight the pathogenesis and suggest therapeutic strategies.

Spontaneous pneumomediastinum in H1N1 infection: uncommon complication of a common infection

H1N1 viral infection leads to complications, such as pneumonia, respiratory failure, myocarditis and encephalitis. Spontaneous pneumomediastinum (SPM) is an extremely rare consequence of H1N1 infection and such cases have been sparsely reported. SPM is identified only by a careful clinical examination and obtaining a timely roentgenogram. We report a case of a young male admitted with H1N1 infection complicated by pneumomediastinum. He was treated successfully with oseltamivir, high-flow oxygen and prompt care in the intensive care unit.

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.

Spontaneous Pneumomediastinum – a Rare Asthma Complication

Asthma is the most common chronic respiratory disease worldwide and its prevalence is increasing. Acute asthma complications are often the reason for admission to emergency healthcare service. In our article we present a case of a rare asthma complication – spontaneous pneumomediastinum with a short review of its incidence, etiology, diagnosis and management. Spontaneus pneumothorax is important to differentiate with secondary pneumomediastinum as well as other conditions as cardiac diseases (acute coronary syndrome, pericarditis, cardiac tamponade, pneumopericardium), lung diseases (pneumothorax, pulmonary embolism, tracheobronchial tree rupture), musculoskeletal disorders, and diseases of the esophagus (rupture and perforation o the esophagus). A chest X-ray is often reliable for diagnosis of spontaneous pneumomediastinum and when inconclusive, can be followed by CT. The management is usually conservative with oxygen and analgesia. Surgery is required only in cases of tracheobronchial compression.

Left-sided Neck Swelling: An Unusual Presentation of a Rare Disease

Pneumomediastinum describes air infiltrating into the soft tissues of the mediastinum. It may be classified as spontaneous or secondary. Spontaneous pneumomediastinum is a rare disease, which usually resolves without intervention. The acute onset of chest pain is the most common presenting complaint.  This article presents a case of spontaneous pneumomediastinum in a 19-year-old man with a short history of rapidly enlarging, painless swelling to the left side of his neck, followed by a discussion of the literature. The diagnosis was made following chest x-ray (CXR) and computed tomography (CT). There was no history of any precipitating event or any risk factors. He was managed conservatively and discharged with outpatient follow-up.  Management of spontaneous pneumomediastinum continues to vary and may benefit from the development of guidelines to standardise management in the future.

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.

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.

Pneumomediastinum in marijuana users: a retrospective review of 14 cases

Introduction

Inhaled marijuana has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum (SPM), a rare finding of free air in the mediastinum likely caused by barotrauma during breathing manoeuvres. The mechanism of inhalation drug use is often not ascertained by physicians, thus little is known about how different smoking techniques precipitate pulmonary injury. We aimed to evaluate the frequency of marijuana use in patients with non-traumatic pneumomediastinum over a 12-month period, identifying additional relevant clinical features or risk factors, and determining the extent to which clinicians record smoking techniques.

Methods

We performed a retrospective chart review over a 1-year period, identifying patients presenting to the hospital with a diagnosis of pneumomediastinum in the absence of trauma, malignancy or iatrogenic cause.

Results

We identified 21 cases, 14 of which (66.7%) were associated with marijuana use, average age was 22.5 years (range 18–30), with male predominance (64.2%). Daily or more use was reported in 50% of cases. Concurrent risk factors including vomiting (57.1%) and coughing (42.9%) were commonly present. The mechanism of smoking was described in only two cases (14.3%).

Discussion

Inhaled marijuana may be an underappreciated risk factor for the development of SPM, caused by air leakage around the bronchovascular sheaths during successive inhalation through a high-resistance smoking apparatus or forced exhalation against a closed glottis. Physicians should be aware of this association in order to provide appropriate counselling. Further research is needed to direct the safe use of smoking devices and techniques.

A Case of Pneumomediastinum and Pneumoperitoneum with Concurrent Massive Subcutaneous Emphysema due to Repositioning of a Tracheostomy Tube

Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.

Pregnancy-associated Spontaneous Pneumomediastinum: A Contemporary Review

Spontaneous pneumomediastinum (SPM), also referred to as mediastinal emphysema, is defined as the presence of free air in the mediastinal cavity without a clear and identifiable cause. Spontaneous pneumomediastinum, in general, is a relatively rare condition, more so in the setting of pregnancy or labor. Clinically, SPM may present as dyspnea, chest pain, and subcutaneous swelling, which may be of serious concern in the setting of pregnancy. A comprehensive literature review revealed that the majority of patients are primiparas, of a younger age, and have term or longer durations of pregnancy. The second stage of labor was found to be most commonly associated with the development of SPM. The pathomechanism suggests that performing the Valsalva maneuver during the active stages of labor may play a role in the development of SPM. Once diagnosed, patients with SPM in pregnancy are admitted to the hospital, treated conservatively, and followed until resolution. SPM must be diagnosed and managed promptly due to rare but serious complications. In addition, dyspnea or chest pain with an unknown etiology should include SPM in the differential diagnosis, especially in the setting of pregnancy and labor.

Musical Instrument-Associated Health Issues and Their Management

Playing musical instruments can bring joy to people, but can also cause a wide variety of health issues that range from mild disorders to potentially fatal conditions. Although sports medicine is an established medical subspecialty, relatively few studies have investigated the health issues associated with musical instruments. Here we present an overview of these health issues. These include infections due to microorganisms, allergic reactions, as well as mechanical injuries from sustained high pressures within the oral, mediastinal, thoracic, and abdominal cavities. For example, wind instruments can potentially harbor thousands of pathogenic organisms. If several players share the same instrument, these instruments present potential hazards in the spread of infections. A fatal case of hypersensitivity pneumonitis in a bagpiper is particularly noteworthy. Similarly, a case of gastrointestinal anthrax in an animal-hide drummer is a reminder of this rare but highly fatal disease. Although not fatal, hearing-related disorders, neuromuscular issues, musculoskeletal problems, and contact dermatitis are also very common among instrumentalists. This review aims to illuminate these under-recognized health issues by highlighting both the common conditions and the rare but fatal cases.

Spontaneous pneumomediastinum in young women: Comparison between anorexia nervosa and nonanorexic patients

Spontaneous pneumomediastinum is a benign, self‐limited condition that mainly affects young people. In this report, we present four cases of this uncommon condition and a review of the current literature. Two cases had no prior significant medical history: one had a history of asthma and the other underwent regular outpatient treatment for anorexia nervosa. The three patients who were not anorexic spontaneously improved within a few days. However, the patient with anorexia nervosa took 2 months to recover. It appears that spontaneous pneumomediastinum is an intractable complication of anorexia nervosa, and the improvement of nutritional status in the patient is essential to manage this condition.

The Effective Treatment with Cyclosporine of a Ulcerative Colitis Patient with Concurrent Idiopathic Thrombocytopenic Purpura Who Subsequently Developed Spontaneous Pneumomediastinum

Although extraintestinal manifestations of inflammatory bowel diseases are not uncommon, few reports have described concurrent idiopathic thrombocytopenic purpura (ITP). Spontaneous pneumomediastinum is also a rare complication of ulcerative colitis (UC). This report describes the case of a 14-year-old boy who experienced recurrent ulcerative colitis 3 months after temporary improvement following treatment with prednisolone (20 mg/day) and granulocyte/monocyte adsorption apheresis. His platelet counts decreased, suggesting ITP. The dosage of prednisolone was increased to 60 mg/day; however, his thrombocytopenia did not improve and he suddenly developed pneumomediastinum. A continuous infusion of cyclosporine increased his platelet counts and improved his ulcerative colitis. Cyclosporine should be considered when steroid-resistant ITP accompanies UC.

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

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

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.

IMAGING DIAGNOSIS-SPONTANEOUS PNEUMOMEDIASTINUM SECONDARY TO PRIMARY PULMONARY PATHOLOGY IN A DALMATIAN DOG

A 1.5-year-old, 23 kg intact male Dalmatian dog was evaluated for acute respiratory insufficiency without a previous history of trauma or toxic exposition. Imaging revealed pneumomediastinum, pneumothorax, diffuse unstructured interstitial pulmonary pattern, pulmonary interstitial emphysema, and pneumoretroperitoneum. Histopathological evaluation of the lungs revealed perivascular and peribronchial emphysema, mild lymphocytic interstitial pneumonia with atypical proliferation of type II pneumocytes in bronchioles and alveoli. A lung disease resembling fibrosing interstitial pneumonia in man and cats has been previously reported in Dalmatians and should be included as a differential diagnosis for Dalmatians with this combination of clinical and imaging characteristics.

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 as a complication in human bocavirus infection

The most common causes of spontaneous pneumomediastinum (SPM) in children are asthma attack and respiratory tract infection. Here, we describe a case of SPM in a human bocavirus-infected 2-year-old boy with bronchiolitis.