HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques B. Jougon Jean-François Velly Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jougon, J. B. Articles by Velly, J.-F. Search for Related Content PubMed PubMed Citation Articles by Jougon, J. B. Articles by Velly, J.-F.

Ann Thorac Surg 2003;75:1711-1714
© 2003 The Society of Thoracic Surgeons

---

Original article: general thoracic

Assessment of spontaneous pneumomediastinum: experience with 12 patients

^a Department of Thoracic Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
^b Department of Ear, Nose, Throat, and Cervicofacial Surgery, General Hospital, University Hospital, Dijon, France

Accepted for publication January 1, 2003.

^* Address reprint requests to Dr Jougon, Service de Chirurgie Thoracique, CHU de Bordeaux, Hôpital du Haut-Lévêque, 33604 Pessac, France
e-mail: jacques.jougon{at}chu-bordeaux.fr

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: The aim of this study is to report a series of spontaneous pneumomediastinum in a population of young, tall, and thin patients with a history of thoracic hyper pressure, and to analyze the assessment required in such patients.

METHODS: A retrospective study of an unicentric series and a review of the literature from 1980 to 2002 were performed.

RESULTS: Between December 1996 and January 2002, 12 patients (mean age, 25 years old; mean height, 172 cm; and mean weight, 63 kg) were admitted with spontaneous pneumomediastinum. In all patients, high intrathoracic pressure by cough or acute effort was the precipitating factor. Most frequent complaints were acute chest pain, asthenia, and subcutaneous emphysema. The following assessment was performed: chest roentgenogram in 12 of 12 patients (12/12); computer tomography (CT) scan in 8/12; bronchoscopy in 7/12; esophagoscopy in 6/12; esophagography in 2/12. Outcome was always uneventful without any recurrence. Hospital stay ranged from 0 to 6 days. The Medline research revealed that articles consist mainly of case reports. Two articles only report a multicentric series of 25 and 36 cases, respectively. No organ perforation was found either in our series or in our review of the literature.

CONCLUSIONS: Spontaneous pneumomediastinum follows alveolar rupture in the pulmonary interstitium. The dissection of gas towards the hilum and mediastinum is produced by an episode of acute high intrathoracic pressure. It affects mostly young people, and this is the case in our series. Endoscopic thoracic assessment may be risky and is not always necessary. Chest CT or esophageal contrast study should be performed in case of diagnostic doubt of esophageal perforation.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Spontaneous pneumomediastinum (SPM) is an uncommon disorder arising most frequently in young adult men with an unknown precise incidence. The disease is little known by physicians, who often require endoscopic explorations to rule out perforation of a chest air-containing viscus. Endoscopic explorations, however, are not always necessary and the subject is still controversial [1, 2]. Previous series and case reports of SPM focused on precipitating factors, clinical presentation, and pathogenesis [3]. We report a unicentric series of 12 patients. The purpose of the study is to determine the minimal assessment required for spontaneous pneumomediastinum, to discuss the causes, and to review the literature.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
A retrospective study of a series of 12 patients admitted to our department for SPM was performed. Patients were first admitted to the emergency department of our university hospital or in a peripheral general hospital. They were secondarily referred to our department for suspicion of perforation of a chest air-containing viscus. In our department, bronchial and esophageal endoscopies are routinely performed. At the beginning of the study, no assessment was defined and each physician decided what the assessment for the patient suffering from pneumomediastinum would be. Data concerning patient history, presenting symptoms, endoscopic and radiologic findings, treatment, and outcome were carefully reviewed. Information concerning long-term recurrence or sequelae was obtained by phone calls to the patient or to his physician.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Between December 1996 and January 2002, 12 patients were admitted for SPM to our department. During the same period 280 patients were admitted for spontaneous pneumothorax and 54 patients for esophageal perforation [4, 5]. There were 11 men and 1 woman ranging in ages from 16 to 46 years old (mean 25 years old). None of them had a medical history of pneumothorax or SPM. The mean height was 172 cm and the mean weight was 63 kg. Spontaneous pneumomediastinum always occurred after high intrathoracic pressure provoked by acute effort or a cough access. The most frequent complaints were acute chest pain, asthenia, noisy voice, and subcutaneous emphysema (Table 1). Odynophagia was present in one patient. Laboratory indicators of infection were normal in all but one patient (patient 10) Chest roentgenogram was performed in all patients, thoracic computer tomography (CT) in 8 patients, bronchoscopy in 7 patients, esophagoscopy in 6 patients, and esophagography in 2 patients (Table 2). Chest roentgenogram and CT revealed the pneumomediastinum in all patients (Figs 1 and 2). Bronchoscopy was normal in all patients except in patient 10, exhibiting a bronchial inflamed tree with clear but thick sputum. The patient was suffering from an acute bronchitis. Esophagoscopy and esophagography were normal in all patients. Treatment consisted of rest, analgesics for all patients, and nebulized therapy for patient 10. The outcome was always uneventful and discharge occurred from day 0 to 6 (mean hospital stay 4 days). None of the patients presented recurrence (follow-up: 98 days to 5 years, mean 19 months). The MEDLINE research revealed that publications consist mainly of case reports. Two articles only report a multicentric series of 25 patients [3] and 36 patients [6], respectively. No organ perforation was found in our review of the literature.

View larger version (117K): [in this window] [in a new window]   Fig 1. Chest roentgenogram illustrating a pneumomediastinum (arrows).

View larger version (113K): [in this window] [in a new window]   Fig 2. Computer tomographic scan illustrating air infiltrating the mediastinum (arrows) without pneumothorax.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Demography of our series is similar to others [3, 9]: young, tall, and thin men are mainly concerned. It seems likely that they present predisposing anatomic factors, such as elastic tissues fragilities.

The pathophysiology was initially described by Macklin and Macklin in 1944 [11] on the basis of laboratory animal experiments, and more recently in a case report by Kaneki and coworkers [12]. SPM would result from the rupture of distal pulmonary alveoli, allowing bubbles to dissect along the vascular sheaths and connective tissue planes to the mediastinum. In the case report by Kaneki and coworkers [12], the CT scan revealed the presence of air in a tubular shape along the pulmonary artery in one segment of the left lung. This can be caused by sustained Valsalva maneuvers such as coughing, vomiting, forceful defecation, strenuous effort, labor [13, 14], asthma attack [15], sneezing [2], or inhalational drug use [16].

Potential serious complications, such as tension pneumomediastinum leading to cardiac compression, are possible. They were induced in laboratory experiments by Macklin and Macklin [11], but were never reported in humans. Cessation of high pressure in the alveoli stops the passage of air.

The main differential diagnosis is spontaneous esophageal perforation (Boerhaave’s syndrome) and worrisome symptoms, signs and abnormal results from simple investigations requires prompt surgery [1]. They include fever, hypotension, odynophagia, pronounced dysphagia, leukocytosis, and pleural effusion. Vomiting is often found as a preceding symptom [17]. The initial investigation should include a CT scan or a water-soluble contrast esophagogram. To us, the esophagoscopy may be a dangerous procedure in such patients when it is not performed by trained surgeons accustumed with the pathology, which may turn a contained into a noncontained perforation. Inducing cough may even, like bronchoscopy, facilitate the passage of air from the ruptured alveoli to the mediastinum along the bronchovascular tissue sheath, thus enhancing pneumomediastinum. For these reasons, some reports argue it is contraindicated. We routinely perform rigid esophagoscopy in the management of esophageal perforation and have noticed no incident [5], preferring it to flexible esophagoscopy, which can also be dangerous by inducing air insufflations into the mediastinum. In our series, 6 patients underwent a rigid esophagoscopy performed immediately after the bronchoscopy: no increasing swelling was noticed. Only one patient (patient 10) had worrisome signs, dysphagia and fever, which justified endoscopic explorations. At the end of our study, which is more than 4 years after its beginning, we drastically reduced the assessment in patients presenting SPM. Only a chest roentgenogram was performed in patients 11 and 12.

Treatment of SPM should consist of reassuring the patient, rest, and analgesia when needed. Symptoms usually resolve quickly and the patient can be discharged a few days later. In our series the hospital stay was gradually reduced along the study from 6 days to few hours, although 48-hour medical supervision seems necessary when a CT scan or a contrast esophageal study is not performed.

Recurrence is rare but has been reported in 2 patients [3, 18], with no predicting factor identified. In case of SPM occurring in children, pulmonary function tests are necessary after the acute episode to rule out asthma [15].

Spontaneous pneumomediastinum is probably a more frequent disorder than usually reported because it is underdiagnosed or misdiagnosed. It is usually limited and resolves spontaneously with rest. Assessment should be tailored to each patient’s history and clinical status. Endoscopies should not be recommended routinely. Young, tall, and thin men, who have a history containing any mechanism responsible for the creation of a high intrathoracic pressure and present with neither fever nor pleural effusion, can only be kept under close supervision a minimum of 2 days. Computer tomography scan and esophageal contrast roentgenogram study are needed in case of worrisome associated symptoms, signs, and abnormal results from simple investigations to rule out an esophageal perforation.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Dr Steven Plume for language editing this manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Ralph-Edwards A.C., Pearson G. Atypical presentation of spontaneous pneumomediastinum. Ann Thorac Surg 1994;58:1758-1760.[Abstract]
2. Dechambre S., d’Odemont J.P., Cornelis J.P., Fastrez J. Spontaneous pneumomediastinum after sneezing. Ann Thorac Surg 1995;60:1457.[Free Full Text]
3. Abolnik I., Izidore S.L., Breuer R. Spontaneous pneumomediastinum. A report of 25 cases. Chest 1991;100:93-95.[Abstract/Free Full Text]
4. Dubrez J., Choukroun E., Jougon J., Delaisement C., Velly J.F. Symphyse pleurale par chirurgie vidéo-assistée pour pneumothorax spontané. Évolution et complications. A propos de 277 cas. J Chir Thorac Cardiovasc 1998;4:129-134.
5. Jougon J., Delcambre F., Mac Bride T., Minniti A., Velly J.F. The mortality of iatrogenic esophageal perforations is high: report of 54 cases. Ann Chir 2002;127:26-31.[Medline]
6. Kaneki T., Kubo K., Kawashima A., Koizumi T., Sekiguchi M., Sone S. Spontaneous pneumomediastinum in 33 patients: yield of chest computed tomography for the diagnosis of the mild type. Respiration 2000;67:408-411.[Medline]
7. Laennec R.T.H. A treatise on diseases of the chest and on mediate auscultation, 2nd Edition London: T & G Underwood, 1819.
8. Hamman L. Spontaneous mediastinal emphysema. Bull John Hopkins Hosp 1939;64:1-21.
9. Hoover L.R., Febinger D.L., Tripp H.F. Rhinolalia: an underappreciated sign of pneumomediastinum. Ann Thorac Surg 2000;69:615-616.[Abstract/Free Full Text]
10. Bejvan S.M., Godwin J.D. Pneumomediastinum. Old signs and new signs. Am J Roentgenol 1996;166:1041-1048.[Abstract/Free Full Text]
11. Macklin M.T., Macklin C.C. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944;23:281-352.
12. Kaneki T., Kubo K., Sone S., Kawashima A. Spontaneous pneumomediastinum: origin identified by chest computed tomography. Intern Med 1998;37:802-803.[Medline]
13. Sutherland F.W.H., Ho S.Y.G., Campanella C. Pneumomediastinum during spontaneous vaginal delivery. Ann Thorac Surg 2002;73:314-315.[Abstract/Free Full Text]
14. Raley J.C., Andrews J.I. Spontaneous pneumomediastinum presenting as jaw pain during labor. Obstet Gynecol 2001;98:904-906.[Medline]
15. Chalumeau M., Le Clainche L., Sayeg N., et al. Spontaneous pneumomediastinum in children. Pediatr Pulmonol 2001;31:67-75.[Medline]
16. De la Cruz Moron I., Reyes Nunez N., Rojas Box J.L. Spontaneous pneumomediastinum in a cocaine user. Arch Bronconeumol 2000;36:231.[Medline]
17. Woolford T.J., Birzqalis A.R., Lundell C., Farrington W.T. Vomiting in pregnancy resulting in oesophageal perforation in a 15-year-old. J Laryngol Otol 1993;107:1059-1060.[Medline]
18. Yellin A., Gapany-Gapanavicius M., Lieberman Y. Spontaneous pneumomediastinum: is it a rare cause of chest pain?. Thorax 1983;38:383-385.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Caceres, S. Z. Ali, R. Braud, D. Weiman, and H. E. Garrett Jr Spontaneous Pneumomediastinum: A Comparative Study and Review of the Literature Ann. Thorac. Surg., September 1, 2008; 86(3): 962 - 966. [Abstract] [Full Text] [PDF]

				I. Macia, J. Moya, R. Ramos, R. Morera, I. Escobar, J. Saumench, V. Perna, and F. Rivas Spontaneous pneumomediastinum: 41 cases Eur. J. Cardiothorac. Surg., June 1, 2007; 31(6): 1110 - 1114. [Abstract] [Full Text] [PDF]

				N. Madershahian, M. Meyn, J. T Strauch, and T. Wahlers Spontaneous Cervical Emphysema and Pneumomediastinum in an 18-year-old Woman Asian Cardiovasc Thorac Ann, February 1, 2006; 14(1): e9 - e11. [Abstract] [Full Text] [PDF]

				A. E. Newcomb and C. P. Clarke Spontaneous Pneumomediastinum: A Benign Curiosity or a Significant Problem? Chest, November 1, 2005; 128(5): 3298 - 3302. [Abstract] [Full Text] [PDF]

				D. Weissberg and D. Weissberg Spontaneous mediastinal emphysema Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 885 - 888. [Abstract] [Full Text] [PDF]

				P. Mihos, K. Potaris, I. Gakidis, E. Mazaris, E. Sarras, and Z. Kontos Sports-related spontaneous pneumomediastinum Ann. Thorac. Surg., September 1, 2004; 78(3): 983 - 986. [Abstract] [Full Text] [PDF]

				G. J. Koullias, D. P. Korkolis, X. J. Wang, and G. L. Hammond Current assessment and management of spontaneous pneumomediastinum: experience in 24 adult patients Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 852 - 855. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques B. Jougon Jean-François Velly Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jougon, J. B. Articles by Velly, J.-F. Search for Related Content PubMed PubMed Citation Articles by Jougon, J. B. Articles by Velly, J.-F.