The unnecessary workups and admissions of adolescents and young adults with spontaneous pneumomediastinum

Spontaneous pneumomediastinum (SPM) is a rare condition in children and young adults that raises concern for esophageal perforation or extension of an air leak, resulting in admissions with multiple interventions performed. To assess our outcomes, and to evaluate our resource utilization, we reviewed our experience with SPM. We conducted a retrospective review of SPM cases in patients aged 5-25 years old occurring between 2011 and 2021 at a single academic tertiary care center. Clinical, demographic, and outcome variables were collected and analyzed, and cohorts were compared using Fischer's Exact Test and Welch's T Test. 166 SPM cases were identified-all of which were Emergency Department (ED) presentations. 84% of the cases were admitted. 70% had Computerized Tomography (CT) scans, with no defined criteria for imaging. Comparison of floor admissions with discharges from the ED showed no significant difference in presenting symptoms, demographics, or outcomes between the two groups. Recurrence was noted in 4 patients with a range of 5.9 months-4.9 years from the initial episode. In the largest SPM study in the pediatric and young adult population, we noted no significant difference in management or outcomes in admitted or ED discharge patients nor those with CT imaging. Our results suggest that a large number of SPM can be managed safely with discharge from the ED.

[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.

Chest and Thorax Injuries in Athletes

Injuries to the chest and thorax are rare, but when they occur, they can be life-threatening. It is important to have a high index of suspicion to be able to make these diagnoses when evaluating a patient with a chest injury. Often, sideline management is limited and immediate transport to a hospital is indicated.

Air Will Find a Way: A Case Report and Literature Review on Tracheostomy-Induced Ectopic Air

Tracheostomy can lead to various complications, one of which is ectopic air in different compartments of the body. Here, we present a rare case of tracheostomy-induced ectopic air: a combination of subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum. This case also presents a literature review on some of the common mechanisms responsible for pneumomediastinum following tracheostomy and the mechanism of pneumoperitoneum following pneumomediastinum. Tracheal injury, tube-related complications, and alveolar rupture are common mechanisms that can lead to pneumomediastinum and subcutaneous emphysema after tracheostomy. Air can then dissect into the abdomen leading to pneumoperitoneum. Knowledge of the anatomic or embryologic development of the thoracoabdominal continuum can help understand the spread of air from one compartment to another. Investigation as simple as a chest X-ray, along with clinical features, can help identify these complications and be used to monitor the course.

Pneumomediastinum in the COVID-19 era: to drain or not to drain?

Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis.  Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.

Spontaneous pneumomediastinum and subcutaneous emphysema after masturbation

Spontaneous pneumomediastinum is a rare condition that mostly affects young men and generally follows a benign and self-limiting course. In contrast to secondary pneumomediastinum, which is caused by trauma, iatrogenic intervention or esophageal perforation, spontaneous pneumomediastinum is triggered by violent coughing, excessive vomiting, strenuous physical exercise or Valsalva maneuver. It results from an abrupt increase in intrathoracic pressure leading to alveolar rupture and air leak along the tracheobronchial tree into the mediastinal cavity. Extended spontaneous pneumomediastinum goes along with subcutaneous emphysema of the chest, neck or head. We present a case of a healthy young man who developed pneumomediastinum and profound subcutaneous emphysema with onset during masturbation. Since there is no literature on spontaneous pneumomediastinum associated with autoerotic experiences, we consider our case an unusual presentation of this entity.

[Spontaneous pneumomediastinum]

INTRODUCTION

Pneumomediastinum, which can be spontaneous or secondary, is defined by the presence of free air in the mediastinum as shown on a chest X-ray and/or chest CT, with or without subcutaneous emphysema. Secondary pneumomediastinum develops in various contexts (thoracic traumatism, perforation of central airway or digestive tract, pneumothorax, barotraumatism complicating mechanical ventilation…). Spontaneous pneumomediastinum , which will be the focus of this review, develops without any of the above-mentioned conditions.

STATE OF ART

Spontaneous pneumomediastinum is a rare entity which usually occurs in young people either without medical history or with an history of asthma. A trigger event is detected in 40% to 60% of cases. Positive diagnosis is made on chest radiographt but thoracic CT is more sensitive. Distinction between spontaneous pneumomediastinum and secondary pneumomediastinum is in general easy but may sometimes be more difficult, particularly in case of oesophageal perforation. The evolution of spontaneous pneumomediastinum is most often benign but, rare complications may occur. Management is most often conservative.

PERSPECTIVES

There is no consensual management of spontaneous pneumediastinum because of the lack of randomized prospective studies. This may be explained by the rarity of the disease. The actual trend is to offer to the patients a conservative treatment, which could be ambulatory in some cases.

CONCLUSIONS

Spontaneous pneumomediastinum is a rare entity developing mainly in young subjects. The evolution is in general benign, justifying a conservative approach.

Risk factors for mediastinitis and mortality in pneumomediastinum

Introduction: Pneumomediastinum (PM) is a self-limiting disease with a good prognosis. Mediastinitis is a rare but potentially fatal complication of PM. Identification of risk factors for mediastinitis is essential for better management. Methods: This is a single-center, retrospective study conducted in a university hospital. Adult patients with PM between January 2016 and June 2020 were involved in the study. The data about age, gender, symptoms, signs, treatment, development of mediastinitis, hospital stay, and mortality were investigated. Results: In total, 79 patients with PM were analyzed. The most common symptom was dyspnea(58;73.4%) and the most common sign was subcutaneous emphysema (48;60.7%). Thirty(37.9%) of them were iatrogenic PM (IPM), while 22 (27.9%) were spontaneous PM (SPM) and27 (34.2%) were traumatic PM (TPM). Mediastinitis developed in 17 (12 from IPM, 4 from TPM,1 from SPM) patients, and 11 (58.8%) of these patients died. The incidence of mediastinitis in the IPM group was significantly higher than in the TPM and SPM group (respectively, P=0,03,P=0,01). There was no significant difference between the age, gender, symptoms, and signs of those with or without mediastinitis. Mortality was lower in TPM and SPM than IPM (respectively,P=0,05, P=0,03), and hematological malignancy was remarkably common in patients who died from mediastinitis in the TPM and SPM group. Conclusion: Mediastinitis and mortality were significantly higher in IPM, while hematological malignancy was remarkably prevalent in patients deceased from mediastinitis in TPM and SPM.

A Case of Spontaneous Pneumomediastinum in Covid-19 Pneumonia

Spontaneous pneumomediastinum (SPM) is defined as free air in the mediastinum thought to be due to non-traumatic rupture of marginal alveoli without evidence of underlying lung disease. Secondary causes must be excluded, including perforations of the esophagus, trachea, and bronchi, due to their propensity for unfavorable outcomes. Infectious etiologies have been documented to cause pneumomediastinum, but this is most frequently observed in the setting of mechanical and noninvasive positive-pressure ventilation (NIPPV). Here we present a case of asymptomatic spontaneous pneumomediastinum in a patient with COVID-19 in absence of mechanical ventilation.

[Spontaneous pneumomediastinum: a rare benign diagnosis in young adults (a case report)]

Le pneumomédiastin spontané se définit par la présence d´air au niveau du médiastin survenant en dehors de tout contexte traumatique, iatrogène ou d´une maladie pulmonaire sous-jacente. C´est une affection rare, qui survient chez le jeune adulte et l´adolescent. Son principal risque est d´être confondu avec un tableau de fistule aéro-digestive, conduisant parfois à la réalisation d´investigations et de mesures thérapeutiques inutiles, voire délétères. Nous rapportons le cas d´un pneumomedisatin spontané survenu chez une femme jeune au décours d´un effort de vomissement.

Pneumopericardium after Laparoscopic Hernia Repair Presents with ST-segment Changes: A Case Report

Introduction

Although rare, iatrogenic cases of pneumopericardium have been documented following laparoscopic surgery and mechanical ventilation. Electrocardiogram (ECG) changes, including ST-segment depressions and T-wave inversions, have been documented in cases of pneumopericardium, and can mimic more concerning causes of chest pain including myocardial ischemia or pulmonary embolism.

Case Report

This unique case describes a patient who presented with chest pain and ST-segment changes on ECG hours after a laparoscopic inguinal hernia repair and who was found to have pneumopericardium.

Conclusion

While iatrogenic pneumopericardium is often self-limiting and rarely requires intervention, it is critical to differentiate pneumopericardium from other etiologies of chest pain, including myocardial ischemia and pulmonary embolism, to prevent unnecessary intervention.

Pneumomediastinum associated with severe pneumonia related to COVID-19: diagnosis and management

BACKGROUND

Pneumomediastinum (PNM) can develop as a severe complication of severe COVID 19 and may be correlated with greater morbidity and mortality. PNM is a rarely reported complication in COVID-19 patients and usually associated with endotracheal intubation.

METHODS

Our aim is to describe the characteristics of patients with PNM in twenty-one patients with COVID-19 related pneumonia and acute respiratory failure in a retrospective case series.

RESULTS

Twenty-one patients were diagnosed, two were treated with high flow nasal cannula, five with non invasive ventilation and four with invasive mechanical ventilation. In four cases PNM was massive PNM was often associated to subcuatneous emphysema; more rarely associated also with pneumothorax. Conservative management was the most used therapeutic strategy.

CONCLUSIONS

PNM should is s serious but not extremely rare complication of severe forms of pulmonary involvement of COVID 19. The clinician should consider this rare complication; moreover, we advise careful attention when clinicians start mechanical ventilation.

Spontaneous pneumomediastinum: A report of two cases at a District General Hospital

Spontaneous pneumomediastinum is a rare condition thought to be caused by excessive Valsalva manoeuvre during the second stage of labour. Women with pneumomediastinum typically presents with chest pain or tightness, dyspnoea, and a tearing sensation around the neck. It is commonly diagnosed with a chest radiograph but further imaging may be necessary to exclude more sinister conditions with similar clinical features. We describe two cases of pneumomediastinum and the different management approaches with different multi-disciplinary input. It is often a self-limiting condition. We propose a management algorithm for women suspected to have pneumomediastinum during the intrapartum and postpartum period.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review

Spontaneous pneumomediastinum (SPM) and pneumothorax (PNX) unrelated to positive pressure ventilation has been recently reported as an unusual complication in cases of severe COVID-19 pneumonia. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. We present a case of COVID-19 pneumonia complicated on day 13 post admission by SPM, PNX and subcutaneous emphysema in a patient with no identifiable risk factors for such complication. The patient received medical treatment for his COVID-19 infection without the use of an invasive or non-invasive ventilator. Moreover, he is a non-smoker with no lung comorbidities and never reported a cough. He was eventually discharged home in stable condition. A comprehensive literature review revealed 15 cases of SPM developing in patients with COVID-19 pneumonia.

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

Introduction

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

Case report

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

Conclusion

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

Spontaneous pneumomediastinum 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.

Pneumomediastinum revisited: we should reconsider usual classification

Pneumomediastinum work-up should focus on differentiating mediastinal organ injuries from alveolar rupture since these two causative mechanisms have a different management and prognosis. After an admission at our Emergency Department, we wanted to challenge the current classification into 'spontaneous' or 'secondary' pneumomediastinum, which reflects the clinical rather than the pathophysiological circumstances and is therefore confusing and inappropriate to our view. We propose a new work-up algorithm based on clinical risks factors and chest CT findings.

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.

Recurrent Spontaneous Pneumomediastinum With Concurrent Pneumorrhachis: A Rare Clinical Entity

Spontaneous pneumomediastinum is the presence of interstitial air in the mediastinal structures without an apparent cause. Pneumorrhachis is defined as the presence of air in the spinal canal. Concurrent pneumorrhachis is an extremely rare epiphenomenon of spontaneous pneumomediastinum without pneumothorax. Diagnosis is confirmed by radiologic imaging of the chest. Spontaneous pneumomediastinum and pneumorrhachis usually resolve with conservative therapy such as bed rest, analgesic agents, and supplemental oxygen. A 20-year-old male patient presented with recurrent spontaneous pneumomediastinum with concurrent pneumorrhachis with a gap of 1 year between the two episodes. Pneumomediastinum and pneumorrhachis resolved with conservative management in both episodes.

Hamman's syndrome (spontaneous pneumomediastinum presenting as subcutaneous emphysema): A rare case of the emergency department and review of the literature

Pneumomediastinum is a rare clinical entity that concerns the clinicians in the emergency department. We present a case of a patient with spontaneous pneumomediastinum (Hamman's syndrome) that presented to our hospital's emergency department with cervical subcutaneous emphysema. A conservative treatment with observation was performed. The patient after 24 hours of observation was discharged with a suggested follow-up.

Spontaneous pneumomediastinum: Case presentation to a college student health clinic

The author describes a case of spontaneous pneumomediastinum (SPM) in a 19-year-old man presenting to a college student health clinic. The author also provides a review on SPM, including clinical manifestations, diagnostic evaluation, and management.

A peculiar case of asymptomatic spontaneous pneumomediastinum

OBJECTIVE

To present a case of asymptomatic spontaneous pneumomediastinum and review available evidence-based workup and management.

CASE PRESENTATION

A young Caucasian adult male with a history of inhalational drug use was admitted to the internal medicine service for evaluation of dehydration and mild rhabdomyolysis. Patient had been on the run from the police and had spent the last days prior to presentation without food, water, or shelter. On admission, patient had no complaints, except for thirst. It was detected on physical exam and chest x-ray that patient had subcutaneous emphysema and pneumomediastinum. The patient was treated conservatively and discharged after a period of observation.

CONCLUSION

Spontaneous pneumomediastinum is benign and seen primarily in young adults. It is more commonly associated with symptoms like chest pain and/or dyspnea, making an asymptomatic case particularly distinctive. The etiologies and precipitating factors are varied and often an apparent cause isn't identified. The diagnostic approach involves chest x-ray and/or computed tomography (CT) chest with further workup being largely unnecessary. The tenants of management include bedrest, analgesics, and supplemental oxygen as needed.

Clinical Significance of Spontaneous Pneumomediastinum

BACKGROUND

Spontaneous pneumomediastinum (SPM) is classified as free air in the mediastinum in the absence of any precipitating cause. It is relatively uncommon, and the clinical significance and risk associated with SPM is not well understood and has not been widely documented in the literature. Our goals were to determine the outcomes of patients who presented with SPM and to determine predictors of severe pathology associated with SPM.

METHODS

From 2004 through 2013, a retrospective review was conducted of patients who presented with SPM to our institution. Patient demographics, comorbidities, laboratory tests, and esophageal perforation were recorded.

RESULTS

In all, 249 patients were discovered to have SPM on chest radiograph or computed tomography scan. Mean age was 38.7 years (range, 17 to 81). Sixty-one percent of patients (151 of 249) were male. Ten percent of all patients (24 of 249) were ultimately discovered to have esophageal perforation, determined by upper endoscopy, upper gastrointestinal series, or intraoperatively during emergent surgery. Age (p < 0.01), pleural effusion (p < 0.01), and elevated white blood cell count (p < 0.01) were the only significant risk factors for esophageal perforation on multivariate analysis.

CONCLUSIONS

Spontaneous pneumomediastinum is usually associated with a benign clinical course. Risk factors for esophageal perforation in these patients include age, elevated white blood cell count, and a pleural effusion. In the absence of abnormal laboratory values or associated radiologic findings, the majority of patients with SPM may be safely observed without the need for further diagnostic testing.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Scary gas: a spectrum of soft tissue gas encountered in the axial body (part II)

Ectopic gas in the mediastinum, subperitoneal abdomen, and superficial soft tissues is concerning and can be seen in the setting of trauma, iatrogenic injuries, infection, and inflammation. It can spread along different dissection pathways and may present remotely from the involved organ as described in part one. Recognition of ectopic gas on imaging and differentiating it from other causes of benign gas is very important as these conditions associated with ectopic gas can lead to rapid patient deterioration and usually require urgent surgery. In part two, the different causes of ectopic and benign gas in the torso are reviewed as well as the imaging features that can help to narrow the differential diagnosis.

[Not Available]

Zusammenfassung. Bei 6–8 % der jungen Erwachsenen sind Thoraxschmerzen Anlass für eine notfallmässige Konsultation. Thoraxschmerzen sind bei jungen Patienten meist unspezifisch, in der Regel benigner Ätiologie und ohne vitale Bedrohung. Wir berichten von einem 16-jährigen Patienten mit thorakalen Schmerzen nach sportlicher Tätigkeit. Radiologisch zeigte sich freie Luft im Mediastinum ohne begleitenden Pneumothorax oder mediastinale Organpathologie. Nachfolgend konnte die Diagnose eines spontanen Pneumomediastinums (PM) gestellt werden. Das spontane oder primäre PM ist eine seltene klinische Entität, die ohne Therapie selbstlimitierend ist. Essenziell ist dabei die Differenzierung vom sekundären PM, dem gefährliche Organläsionen zugrundeliegen und das unbehandelt mit einer hohen Mortalität einhergeht.

Clinical Manifestations of Spontaneous Pneumomediastinum

Background

Spontaneous pneumomediastinum (SPM) is an uncommon disorder with only a few reported clinical studies. The goals of this study were to investigate the clinical manifestations and the natural course of SPM, as well as examine the current available treatment options for SPM.

Methods

We retrospectively reviewed 91 patients diagnosed with SPM between January 2008 and June 2015.

Results

The mean age of the patients was 22.7±13.2 years, and 67 (73.6%) were male. Chest pain (58, 37.2%) was the predominant symptom. The most frequent precipitating factor before developing SPM was a cough (15.4%), but the majority of patients (51, 56.0%) had no precipitating factors. Chest X-ray was diagnostic in 44 patients (48.4%), and chest computed tomography (CT) showed mediastinal air in all cases. Esophagography (10, 11.0%), esophagoduodenoscopy (1, 1.1%), and bronchoscopy (5, 5.5%) were performed selectively due to clinical suspicion, but no abnormal findings that implicated organ injury were documented. Twelve patients (13.2%) were discharged after a visit to the emergency room, and the others were admitted and received conservative treatment. The mean length of hospital stay was 3.0±1.6 days. There were no complications related to SPM except for recurrence in 2 patients (2.2%).

Conclusion

SPM responds well to conservative treatment and follows a benign natural course. Hospitalization and aggressive treatment can be performed in selective cases.

An Unusual Association in an Uncommon Disease: Two Cases of Spontaneous Pneumomediastinum Associated with Pneumorrhachis

Pneumomediastinum, the presence of free air in the mediastinum, is described as spontaneous pneumomediastinum when there is no apparent cause such as trauma, surgery, interventional procedures, or intrathoracic infections. Pneumorrhachis is a rare clinical condition, consisting of intraspinal air. The main causes are iatrogenic, traumatic, and nontraumatic. Spontaneous mediastinum is usually associated with subcutaneous emphysema and, occasionally, with pneumothorax; however, its association with pneumorrhachis is extremely rare. Here, we present two rare cases of spontaneous pneumomediastinum associated with pneumorrhachis caused by vigorous coughing.

Pneumomediastinum as a complication of critical pertussis

BACKGROUND AND AIMS

Pertussis is a common and potentially serious disease affecting mainly infants and young children. In its non-classic presentation, pertussis can be clinically indistinguishable from other respiratory illnesses. Pertussis today often remains underdiagnosed in adults. Our aims was to report a complicated cases of pertussis.

RESULTS

A case of serologically confirmed pertussis occurred in an 18-year-old man presenting with pneumomediastinum, subcutaneous emphysema in the neck and chest, and persistent attacks of coughing with apnea that required treatment in the intensive care unit.

CONCLUSION

Pneumomediastinum and subcutaneous emphysema have never been described in adult patients with pertussis. Physicians should be aware that patients presenting with persistent cough and pneumomediastinum may have pertussis and include this in their differential diagnosis.

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: ten years of our experience in diagnosis and outcome

Spontaneous pneumomediastinum (SPM) is a rare clinical condition that may be mild but also dramatic with sudden onset of chest pain and dyspnea accompanied by swelling and subcutaneous crepitations. The objective of this study was to analyze the clinical presentation and outcome of SPM in a specialized pulmonary tertiary care centre over a 10 years year period. In subsequent followup, we received information related to recurrence episodes of SPM by patients or their GPs physicians. Eighteen patients, 15 (83%) men, mean age 24 years (SD ±7.86) were diagnosed with SPM. Predominant symptoms were chest pain and cough (n=11) then dyspnea (n=9). Asthma was the most common predisposing condition (n=12). Pneumomediastinum was present on chest radiograph in 17 cases (94%), and in one case it was detected only by computed tomography. The mean length of hospital stay was 7 days (SD ±4.4 days). All our patients recovered and there were no complications. Recurrent event occurred in one asthma patient, 2 years after the first episode. Although, SPM is usually a self-limiting and benign condition, close monitoring is necessary. Recurrence is rare, but possible, with no evidence that routine monitoring of those patients is needed.

Recurrent spontaneous pneumomediastinum in a young female: Hamman's crunch revisited(†)

Presence of free air in the mediastinum without any identifiable cause is defined as spontaneous pneumomediastinum (SPM). SPM is more common in young males. The common inciting event leading to SPM are retching, vomiting, acute asthma attack, intense sport activity, inhalation of drugs and weight loss as seen in anorexia nervosa. Analgesics and rest is the mainstay of treatment. Recurrence of SPM is rare. We present a case of recurrent SPM occurring in a young female within few months interval. We also present a brief literature review.

Pneumomediastinum: etiology and a guide to diagnosis and treatment

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Pneumomediastinum and pneumopericardium in an 11-year-old rugby player: a case report

OBJECTIVE

Pneumomediastinum and pneumopericardium are rare occurrences in young athletes, but they can result in potentially life-threatening consequences.

BACKGROUND

While involved in a rugby match, an 11-year-old boy received a chest compression by 3 players during a tackle. He continued to play, but 2 hours later, he developed sharp retrosternal chest pain. A chest radiograph and an echocardiograph at the nearest emergency department showed pneumopericardium and pneumomediastinum.

DIFFERENTIAL DIAGNOSIS

Sternal and rib contusions, rib fractures, heartburn, acute asthma exacerbation, pneumomediastinum, pneumopericardium, pneumothorax, traumatic tracheal rupture, myocardial infarction, and costochondritis (Tietze syndrome).

TREATMENT

Acetaminophen for pain control.

UNIQUENESS

To our knowledge, this is the only case in the international literature of the simultaneous occurrence of pneumomediastinum and pneumopericardium in a child as a consequence of blunt chest trauma during a rugby match.

CONCLUSIONS

Pneumomediastinum and pneumopericardium may be consequences of rugby blunt chest trauma. Symptoms can appear 1 to 2 hours later, and the conditions may result in serious complications. Immediate admission to the emergency department is required.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Spontaneous pnemomedastinum in acute severe asthma

Spontaneous medastinal emphysema, as a complication of acute severe asthma, is an uncommon entity. It usually runs a benign course and resolves spontaneously without any surgical intervention. Recognition of this complication is critical, as it has to be differentiated from other life threatening ones including oesophageal rupture, Boerhave’s syndrome, acute coronary syndrome and pulmonary embolism. This case is being presented to emphasize its recognition in the differential diagnosis of complications arising from acute severe asthma and to present its management strategy in detail.