Subcutaneous emphysema and pneumomediastinum as presenting manifestations of neonatal tracheal injury

Neonatal tracheal injury/perforation is an uncommon complication of traumatic deliveries or endotracheal intubation. We present a case of neonatal tracheal injury following delivery at term that presented with subcutaneous emphysema and pneumomediastinum before any attempt at intubation. The clinical course, treatment, and outcome are described.

Non-traumatic thoracic emergencies: acute chest pain: diagnostic strategies

Acute chest pain may represent the initial and/or accompanying symptom in a variety of disease processes that may occur in the cardiovascular system, respiratory system, gastrointestinal tract, or musculoskeletal system. Although clinical history, risk factors, and physical examination are important factors in establishing the etiology of symptoms in patients presenting with acute chest pain, imaging modalities are frequently utilized. Noncardiac causes of acute chest pain are reviewed in this paper with special reference to the most recently published literature and emphasis on acute aortic diseases. Imaging modalities with indication of appropriateness, optimal technique and practical keys for interpretation are discussed.

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma

STUDY OBJECTIVE

We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries.

METHODS

We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries.

RESULTS

Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention.

CONCLUSION

Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.

[Severe mediastinal emphysema after temporal gunshot with a gas revolver]

Injuries after a close contact gunshot with clear or tear gas cartridges can lead to severe and life threatening complications. The high pressure of the gas may damage soft tissue, bones and organs. This mechanism is able to cause mediastinal emphysema, rupture of upper and lower pharyngeal, esophageal and tracheal structures far away from the initial trauma with diagnostic findings which are may be difficult to interpret. This case report presents a mediastinal emphysema in a 17 year old man following a temporal shot with a gas revolver. The diagnostics, focussed on CT and X-ray imaging, and the therapeutic concept of such cases will be discussed.

Comparative study of mediastinal emphysema as determined by etiology

OBJECTIVE

To evaluate the difference in the clinical features of mediastinal emphysema as classified into three groups based on etiology; patients in whom it was spontaneous with unknown etiology (A group), those in whom it was secondary to bronchial asthma (B group), and those in whom it was secondary with other respiratory diseases (C group).

PATIENTS

Forty-three cases (45 episodes) with mediastinal emphysema treated at Kawasaki Medical School Kawasaki Hospital between April 1985 and March 2000 (A group: 17 cases, B group: 17 cases, C group: 9 cases).

RESULTS

The average ages of the A and B groups were of little significance. Most of the patients in the A group were males with a thin body. Three patients in the A group had episodes of pneumothorax or mediastinal emphysema in their past history. Five patients in the A group had Hamman's sign on physical examination. In all of the patients in the C group, mediastinal emphysema was accompanied by subcutaneous emphysema, whereas only eight patients in the A group had subcutaneous emphysema. The prognosis was good for A and B groups because the mediastinal emphysema disappeared within 10 days, but was poor in the C group because its disappearance was very late compared with that in the other two groups and skin incision was required in three patients in the C group due to severe subcutaneous emphysema. CONCLUSIONS We suggest that the existance and kind of underlying diseases significantly affect the method of treatment and the prognosis.

Bronchiolitis obliterans in a case of juvenile rheumatoid arthritis presented with pneumomediastinum

We present a case of bronchiolitis obliterans associated with juvenile rheumatoid arthritis in whom pneumomediastinum was the presenting manifestation. Diagnosis of bronchiolitis obliterans was made on the basis of the clinical history, pulmonary function tests and high-resolution computerized tomography scan findings. Pneumomediastinum resolved in a few days following high-dose nasal oxygen. This case shows that bronchiolitis obliterans can occur in patients with juvenile rheumatoid arthritis. Complicating pneumomediastinum in such cases should be considered as an indication of underlying bronchiolitis obliterans.

Persistent pneumomediastinum and dermatomyositis: a case report and review of the literature

We describe a 42-year-old man with dermatomyositis and interstitial lung disease who presented with anterior neck pain and dyspnoea. Chest radiographs showed subcutaneous emphysema, pneumomediastinum and diffuse reticulonodular infiltration in both lungs. After the administration of high doses of prednisolone, an improvement of pulmonary function and respiratory symptoms was observed but the pneumomediastinum persists 12 months after diagnosis, and without any complication. We review the cases that have been reported thus far of pneumomediastinum associated with dermatomyositis and discuss the possible mechanisms involved. We conclude that pneumomediastinum is not an uncommon complication of dermatomyositis and that its aetiopathogenesis remains very unclear.

Spontaneous pneumomediastinum presenting as jaw pain during labor

BACKGROUND

Pneumomediastinum, or presence of free air within the mediastinum, is a rare complication of labor. Common symptoms of this condition include chest pain, dyspnea, and subcutaneous emphysema.

CASE

A woman complained of right jaw pain 90 minutes after the onset of her second stage of labor. On examination, she was found to have swelling and crepitus over her face, neck, and supraclavicular region. A chest radiograph demonstrated a pneumomediastinum, which resolved spontaneously.

CONCLUSION

Pneumomediastinum is associated with Valsalva maneuvers such as those seen during the second stage of labor. We report jaw pain as an unusual presenting symptom of this rare condition. Familiarity with the presenting symptoms of a pneumomediastinum is imperative for appropriate treatment and monitoring for significant complications.

Local interstitial emphysema caused by meconium aspiration: report of one case

A neonate of meconium aspiration syndrome presented with respiratory distress and bilateral pneumothorax. The image studies, including chest X-ray, chest computed tomography and operation finding all showed cystic changes in the right lung. Therefore congenital cystic lesions of lung was the first impression. However, the pathologic report disclosed meconium aspiration with interstitial emphysema.

[Pneumomediastinum in children]

Pneumomediastinum in children is diagnosed in two circumstances: cervical subcutaneous emphysema or radiological findings. The predominant symptoms are dyspnoea, stabbing chest pain, sore throat and dysphagia. Traumatic injuries and pulmonary diseases such as asthma are the most common causes of pneumomediastinum. It may rarely result from iatrogenic manoeuvres or acidocetosis. Spontaneous mediastinal emphysema is seldom reported in children. Chest X-ray films are essential investigations. The treatment is directed towards the underlying cause, with conservative management being sufficient in most cases. However, the risk of surveying of pneumothorax or tension pneumomediastinum justifies close clinical follow-up in a specialised care unit. The onset of these pathologies necessitates a more aggressive therapy by aspiration through percutaneous catheter placed in the mediastinum.

Gas extravasation complicating laparoscopic extraperitoneal inguinal hernia repair

Carbon dioxide can extravasate from the abdominal cavity during insufflation and result in pneumomediastinum, pneumothorax, and subcutaneous emphysema. We report a case of unilateral pneumothorax with pneumomediastinum and subcutaneous emphysema after laparoscopic extraperitoneal bilateral inguinal hernia repair. Additionally, we discuss the pathophysiology, diagnostic work-up, and management of this malady. Because of the natural resolution of CO2 pneumothoraces, observation for asymptomatic patients is appropriate, whereas tube thoracostomy should be reserved for symptomatic patients. It is utmost importance to determine the etiology of gas extravastion and consider other complications such as airway or esophageal injury or pulmonary barotrauma.

Subcutaneous emphysema and pneumomediastinum: a cause of low-voltage electrocardiogram

The authors report the occurrence of diffuse low voltage and the loss of R-waves in the precordial leads in a standard 12-lead electrocardiogram, suggestive of an anterior wall myocardial infarction, in a patient with subcutaneous emphysema and pneumomediastinum.

Spontaneous pneumomediastinum in children

SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

[Spontaneous pneumomediastinum: radiologic and CT study]

Pneumomediastinum may be due to various diseases. In young adults without thoracic trauma or pulmonary or mediastinal diseases pneumomediastium is secondary to mild strain or cough. This disease is defined as spontaneous pneumomediastinum or Hamman's syndrome, with a good prognosis, and doesn't need any treatment. X-ray and CT of the chest can provide correct diagnosis and adequate treatment.

[Spontaneous pneumomediastinum and idiopathic pulmonary fibrosis]

The association between pulmonary fibrosis and pneumomediastinum is infrequent. Computed tomography is the suited method for the detection of small pneumomediastinum, which is difficult to detect by chest radiography. A case of idiopathic pulmonary fibrosis, with frequent and violent cough, with pneumomediastinum and cervical subcutaneous emphysema, without pneumothorax, probably caused by rupture of bullae is presented. The outcome was favourable with symptomatic treatment.

[Pneumomediastinum following drug abuse]

Pneumomediastinum is termed spontaneous when not associated with trauma or other identifiable pathological process. There are several reports of pneumomediastinum following narcotic drug inhalation or smoking while applying positive pressure. We describe a 37-year-old male drug addict, hospitalized after having being found unconscious with shortness of breath. CT scan demonstrated bilateral pneumonia with pneumomediastinum. After a day of mechanical ventilation he gradually recovered and the mediastinal air disappeared. Pneumomediastinum may occur in addicts but usually has no dangerous clinical consequences. If there is respiratory deterioration another cause should be sought.

Bilateral pneumothorax with extensive subcutaneous emphysema manifested during third molar surgery. A case report

This report describes a case of bilateral pneumothorax with extensive subcutaneous emphysema in a 45-year-old man that occurred during surgery to extract the left lower third molar, performed with the use of an air turbine dental handpiece. Computed tomographic scanning showed severe subcutaneous emphysema extending bilaterally from the cervicofacial region and the deep anatomic spaces (including the pterygomandibular, parapharyngeal, retropharyngeal, and deep temporal spaces) to the anterior wall of the chest. Furthermore, bilateral pneumothorax and pneumomediastinum were present. In our patient, air dissection was probably caused by pressurized air being forced through the operating site into the surrounding connective tissue.

Spontaneous subcutaneous temporal emphysema

The presence of air in the temporal regions is an uncommon presentation of spontaneous pneumomediastinum. As terminal alveoli rupture, air dissects along bronchovascular shafts. Usually, air travels either in a superior or inferior direction. Thus, extensive spontaneous subcutaneous emphysema accompanied by both cervical and retroperitoneal emphysema is rarely encountered. We present an unusual case of spontaneous pneumomediastinum, pneumoretroperitoneum, and cervical and facial emphysema presenting as bilateral painless temporal swelling. To our knowledge, this association has not been reported. Treatment involves observation for potentially life-threatening sequelae.

An atypical presentation of spontaneous pneumomediastinum

Spontaneous pneumomediastinum is a rare condition and a most uncommon complication of sporting activity. We describe a case of spontaneous pneumomediastinum in a 17-year-old boy while playing football with no history of blunt trauma to the chest. The patient presented with symptoms and signs suggestive of an oesophageal perforation. The importance of correct investigations and subsequent management are discussed.

Pneumomediastinum acquired by glass blowing

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

Traumatic pneumomediastinum caused by isolated blunt facial trauma: a case report

Traumatic pneumomediastinum is most often identified as an incidental finding in the setting of blunt or penetrating neck, chest, or abdominal trauma. There are only a few cases in the medical literature of a pneumomediastinum following isolated facial trauma. We present a patient who sustained fractures of the lateral and anterior walls of the right maxillary sinus, floor of the right orbit, and right zygomatic arch. Subcutaneous emphysema overlaid the right facial region and extended to the left side of the neck and into the mediastinum. We describe this unusual complication with respect to the anatomic relations of the facial and cervical fascial planes and spaces with the mediastinum.

[Spontaneous pneumomediastinum as a complication of asthma in adultsand adolescents]

The objective of this study was to examine the percent of spontaneous pneumomediastinums (SPM) as a complication of asthma in children and adolescent, and to examine the symptoms and clinical signs which predict SPM. A retrospective analysis was performed of patients discharged from Srebrnjak Hospital between 1988 and 1991 with the diagnoses of asthma and SPM. Ten cases (8 males and 2 females) aged 4-19 years were compared with 50 hospitalized patients. SPM was found in 4.96% of patients. Mean age of patients with SPM and asthma was 11.2 and of control patients 11.45 years. Chest pain was reported in 5/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). Subcutaneous emphysema was detected in 9/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). There was no difference in respiratory distress, partial oxygen pressure and oxygen saturation, heart rate and respiratory rate between cases and controls (p > 0.05). Systolic pressure was higher in children with SPM, but the values were within normal limits. During hospitalization in 3 patients with SPM partial left pneumothorax developed, in 1 partial bilateral pneumothorax and in 2 pneumopericardium. Subcutaneous emphysema is a significant specific clinical sign, and chest pain is a predominant symptom in the diagnosis of SPM. The patients with asthma and SPM must be treated in hospital because of potential further complication.

[A case of respiratory distress syndrome complicated by the development of interstitial emphysema and pneumomediastinum]

A 15-year-old patient has been admitted to the intensive care unit for severe respiratory distress syndrome that developed as a result of pneumonia. Interstitial lung edema was confirmed by computer-aided tomography. It was successfully treated by positive pressure ventilation (PPV). Although PEEP did not exceed 7 cm H2O, PPV was complicated by interstitial emphysema, pneumomediastinum, and bilateral pneumothorax as a result of barotrauma. Pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP) were monitored. High PCWP values were inconsistent with the diagnosis of acute respiratory distress syndrome. The authors suggest that high PCWP was caused by high intraalveolar pressure, pneumomediastinum, and venule constriction in the hypoxic sites of the lung.

Pneumomediastinum due to Venturi jet ventilation used during microlaryngeal surgery in a previously neck-irradiated patient

Serious complications secondary to Venturi jet ventilation used during microlaryngoscopy are rare, but when they occur, they may pose a life-threatening emergency. We report the case of a 45-year-old woman, previously treated with 70 Gy of irradiation for a T1 laryngeal carcinoma, who developed pneumomediastinum and subcutaneous emphysema after the use of Venturi jet ventilation. Keeping in mind the histologic changes to the irradiated structures, we suggest more caution when using Venturi jet ventilation in patients who have recently undergone neck irradiation therapy.

Subcutaneous emphysema and pneumomediastinum after endotracheal anaesthesia

INTRODUCTION

We report a case of subcutaneous emphysema and pneumomediastinum that presented postoperatively after tracheal extubation.

CLINICAL PICTURE

A 51-year-old man had an uneventful anaesthesia lasting about 6.5 hours. Intubation was performed by a very junior medical officer and was considered difficult. He developed sore throat, chest pain, numbness of both hands and palpable crepitus around the neck postoperatively. Chest X-ray revealed diffuse subcutaneous emphysema, pneumomediastinum and possible pneumopericardium.

TREATMENT

He was treated conservatively with bed rest, oxygen, analgesia, antibiotic prophylaxis, reassurance and close monitoring.

OUTCOME

The patient made an uneventful recovery.

CONCLUSIONS

We discussed the possible causes.

Rhinolalia: an underappreciated sign of pneumomediastinum

Thoracic surgeons are involved in the diagnosis and management of patients with mediastinal emphysema because of the potentially life-threatening conditions that either must be treated emergently or excluded. Although the classic findings of pneumomediastinum have been described for nearly 60 years, an underappreciated finding is the presence of rhinolalia. Case reports of this finding are sporadic and absent from the thoracic surgical literature. The presence of rhinolalia in association with spontaneous pneumomediastinum is highlighted in the following case presentation and prior reports are reviewed.

Air leak syndrome as one of the manifestations of bronchiolitis obliterans organizing pneumonia

A 46-year-old man developed respiratory distress with air leak syndrome (ALS), including pneumothorax, pneumomediastinum, and subcutaneous emphysema. Open lung biopsy was performed and revealed the histopathologic evidence of bronchiolitis obliterans organizing pneumonia (BOOP), which responded well to steroid treatment. As far as we know, this appears to be the first case of BOOP presenting with ALS as one of its major complications.

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

CASE REPORT

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

CONCLUSION

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

[Pneumopericardium in an asthmatic patient. A case report and review of the bibliography]

Pneumopericardium is an uncommon but potentially serious condition of which leading cause is mechanical ventilation in infants suffering respiratory distress syndrome. In adults, however, the most common causes are iatrogenic in diagnostic and therapeutic procedures, as well as traumatic lesions. We describe a case of pneumopericardium in a teenager suffering an asthma crisis. A review of the literature is presented, stressing the most relevant findings of the physical examination and habitual laboratory tests.

Pneumomediastinum: the Valsalva crunch

The following case presentations illustrate the diverse clinical manifestations and benign self-limited course of spontaneous pneumomediastinum. The discussion includes the mechanisms involved, the symptoms, the radiographic findings, the potential complications, the exclusionary diagnosis, and the appropriate management of this condition.

[Tracheobronchial perforations--a complication after mouth, maxillary and facial surgery]

After difficult endotracheal intubation in oral and maxillofacial surgery, esophageal or tracheal injuries can cause mediastinal, pericardial or cervicofacial soft tissue emphysema. If a patient has of thoracic pain after general anesthesia, mediastinal emphysema should be taken into consideration because of the possibility of subsequent life-threatening complications. Diagnosis can be established with computed tomography and fiber-endoscopy. We present the diagnostic and therapeutic management of two patients.