Two cases of spontaneous epidural emphysema during asthmatic attack

Two cases of spontaneous epidural emphysema that occurred during asthmatic attacks in a 13-year-old and a 15-year-old are reported here. Epidural emphysema was diagnosed in both cases by using computed tomography (CT), and in 1 case by using magnetic resonance imaging (MRI). Neither patient had neurological findings. Both patients were discharged with no respiratory difficulties. It is generally believed that a diagnosis of epidural emphysema can only be made on CT. In this report, MRI was used to make the diagnosis of subdural emphysema, and it demonstrated that the air was localized within the epidural fat.

Barotrauma-associated posterior tension pneumomediastinum, a rare cause of cardiac tamponade in a ventilated neonate: a case report and review of the literature

Ventilation-associated neonatal barotrauma comprises a spectrum of conditions including pneumothorax, pulmonary interstitial emphysema, pneumopericardium and pneumomediastinum. Whilst pneumothorax is common, mediastinal and particularly posterior mediastinal air collections are rare. We report the case of a neonate, presenting with life threatening pericardial tamponade secondary to posterior tension pneumomediastinum. The infant was successfully resuscitated with an emergency left lateral thoracotomy and chest drain insertion. We believe this to be the first such case reported in the literature. We discuss aspects of pathophysiology, diagnosis and management relating to posterior pneumomediastinum.

CONCLUSION

Posterior pneumomediastinum is rare, but can potentially cause fatal tamponade. Such cases must be managed in a tertiary centre where cardiology and surgical expertize are available.

[Pneumoperitoneum, pneumoretroperitoneum, bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema due ERCP]

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential procedure in the diagnosis and treatment of biliopancreatic diseases. Complications of this procedure are potentially serious, being necessary to know how to recognize them for the application of the appropriate treatment. We report the case of a 79-year-old woman who developed a massive subcutaneous emphysema, bilateral pneumothorax, retropneumomediastinum, retropneumoperitoneum and pneumoperitoneum due to iatrogenic duodenal injury secondary to ERCP. The clinical suspicion for early diagnosis of iatrogenic injury after ERCP will determine the correct treatment of this complication and will achieve better outcomes.

An unpredicted case of tracheal necrosis following thyroidectomy

Tracheal rupture is a rare condition, and its most common cause is head and neck injury. Nontraumatic disruption of the anterolateral fibrocartilaginous trachea is an exceptional complication following thyroidectomy with few cases reported in literature. We report a case of upper tracheal necrosis arising 15 days after uneventful total thyroidectomy and resulted in pneumomediastinum and subcutaneous emphysema. The patient felt a sudden pop in his neck following an episode of vigorous coughing and experienced rapid swelling in his neck. The presence of pneumomediastinum was diagnosed on chest Computed Tomography scan and bronchoscopy visualized a small perforation on the right side of the anterolateral tracheal wall. The first interesting aspect is that several factors (female gender, thyrotoxic goiter, wound infection or excessive use of diathermy) reported as possible cause of anterior tracheal necrosis in the previous reports are unlike for the present case. The second unusual point is the spontaneous healing of the tracheal tear. Considering the no-critical ill condition of the patient and the size of the tear we decide for a conservative treatment rather than surgical repair. Finally, our report underlights that the presence of subcutaneous emphysema following thyroidectomy should alert the possible existence of tracheal rupture. The favourable outcome of our patient shows that small tracheal perforation due to tracheal necrosis may be successfully treated with conservative treatment.

[Pneumomediastinum as a rare cause of retrosternal chest pain--report of two cases]

Pneumomediastinum (PM) is a rare cause (the rate varies from 1:8500 to 1:30000 patients) of pain in the chest. This is generally a benign entity resulting from alveolar rupture and propagation of the air into the mediastinum that affects mainly young adults. It may appear however as a complication of different procedures within the chest. Asthma, cough, vomiting, illicit drug use and all activities that require the Valsalva maneuver and/or intense breathing work or exercise were identified as predisposing factors of PM. We report cases of two patients admitted within some months to the emergency department due to chest pain. Due to acute onset of symptoms and a presence of a loud murmur along the left border of the sternum the acute pericarditis was suspected. However, after careful and detailed examination acute coronary syndrome and pericarditis were excluded. Radiologic examination and computed tomography of the chest revailed the presence of air in the mediastinum in both cases. After the diagnosis of pneumomediastinum antiinflammatory agents and antibiotics were administered. Recovery was uneventful, within two weeks form the onset a complete resolution of radiologic changes were observed.

[Spontaneous pneumomediastinum--a case review]

The authors present in the following case review a patient with spontaneous pneumomediastinum which can be on of the causes of acute chest pain and it is necessary to think about it in the differential diagnosis of this condition.

[Pneumomediastinum and subcutaneous emphysema complicating active labour]

Subcutaneous emphysema and pneumomediastinum were first described by Hamman in 1945. Spontaneous pneumomediastinum is an uncommon, self-limiting condition caused by alveolar rupture and usually results from bronchial hyper-reactivity or barotraumas. We report a case describing a 25 year old patient in her first pregnancy, who during active labour developed subcutaneous emphysema and pneumomediastinum. Pneumomediastinum in labour is a rare complication to Valsalva maneuver, and it is diagnosed with a computed tomography. The most common symptoms are chest pain, dyspnea, neck pain and odynophagia.

Pneumomediastinum and subcutaneous emphysema in a cat associated with necrotizing bronchopneumonia caused by feline herpesvirus-1

This report describes a 1-year-old cat with acute dyspnea. Thoracic radiography revealed a pneumomediastinum and severe subcutaneous emphysema. Lower airway surgical exploration was unable to determine the cause. At postmortem examination, acute necrotizing bronchopneumonia and fibrinonecrotic tracheitis due to feline herpesvirus-1 were diagnosed.

Pneumomediastinum and emphysema in a case of a soft bronchial foreign body aspiration in a child. A case report

Foreign body aspiration is a frequent cause of hospitalization in pediatric ENT units. Pneumomediastinum and subcutaneous emphysema are possible complications of tracheobronchoscopy with foreign body removal, but it is rare, that the foreign body causes the complications itself. The authors present a very rare case of a soft bronchial foreign body aspiration in a child with such complications.

[Pneumomediastinum in a child]

BACKGROUND

Pneumomediastinum is a rare, benign condition in which air leaks through the alveolar membrane and collects in the mediastinum. Typical clinical symptoms include chest pain and dyspnoea. In the absence of underlying pathology, conservative treatment is sufficient for remission. Complications are infrequent.

CASE DESCRIPTION

We present a case of a 14-year-old boy with pneumomediastinum arising during physical exercise after an earlier episode of coughing. Physical examination showed subcutaneous emphysema in the neck and praecordial systolic crepitations. A chest X-ray revealed air in the mediastinum. Conservative treatment was sufficient for full clinical and radiographic recovery.

CONCLUSION

There was no underlying pathology. The diagnosis was therefore a 'spontaneous pneumomediastinum' possibly caused by a Valsalva manoeuvre after physical exercise and chronic coughing.

Adjunctive effects of cyclosporine and macrolide in rapidly progressive cryptogenic organizing pneumonia with no prompt response to steroid

Cryptogenic organizing pneumonia (COP) generally responds well to corticosteroids with a favorable outcome. However, it can rapidly worsen and lead to respiratory failure that is refractory to corticosteroids. Adjunctive drugs have been used in refractory cases with various outcomes, but treatment experience is still lacking. We present a case of rapidly progressive COP accompanying air leak syndrome, which showed no prompt response to corticosteroids alone but gradual improvement with the addition of cyclosporine and macrolide. This case report supports the existing literature suggesting that an early therapeutic trial of this drug combination might be considered in COP patients whose condition worsens despite corticosteroid administration.

[Complications of endoscopic video-assisted surgical interventions in gynaecology]

An analysis of specific complications in gynaecological endovideosurgery has been conducted, such as occurrence of extra-abdominal gas after laparoscopic surgery or resorption of the irrigation solution in hysteroscopy. Possible mechanisms of subcutaneous emphysema, pneumothorax, mediastinal emphysema and hyperhydration development are presented along with discussion of diagnosing and treatment methods.

Iatrogenic tracheal tear

Large post intubation tracheal tears are usually detected intra-operatively due to unstable signs namely impaired ventilation and mediastinal emphysema and often require surgical management. Smaller tracheal tears are often missed during anaesthesia and recognized during the postoperative period. Conservative management should be considered in these latter cases.

[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.

Dysphonia and chest pain as presenting symptoms of pneumomediastinum

Spontaneous pneumomediastinum (SPM) is a rare but generally benign condition characterized by the presence of free air in the mediastinal space that is unrelated to trauma or medical procedure. We describe a case of a 25-year-old woman who presented to the emergency room with a chief complaint of dysphonia, and chest pain. An X-ray of the neck and CT of the chest were performed and showed findings consistent with a pneumomediastinum. Supportive treatment led to an uneventful recovery. We discuss the differential diagnosis of the coexisting chest pain and dysphonia in the diagnosis of SPM.