Ann Thorac Surg 2004;78:711-713
© 2004 The Society of Thoracic Surgeons
Case Report
Spontaneous pneumomediastinum
Thomas E. Langwieler, MDa*,
Katharina D. Steffani, MDa,
Dean P. Bogoevski, MDa,
Oliver Mann, MDa,
Jakob R. Izbicki, MD, PhDa
a Department of Surgery, University Hospital Hamburg- Eppendorf, Hamburg, Germany
Accepted for publication September 4, 2003.
* Address reprint requests to Dr Langwieler, Department of Surgery, University Hospital Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
e-mail: langwieler{at}uke.uni-hamburg.de
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Abstract
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Pneumomediastinum is the presence of air in the mediastinum. Spontaneous pneumomediastinum (SPM) is an infrequent, benign, and self-limiting condition that predominantly affects young males and pregnant females. It is important to distinguish pneumomediastinum symptoms from similar clinical findings that require immediate treatment, such as cardiac tamponade, angina pectoris, dissecting aortic aneurysm, mediastinitis, and pulmonary embolism. This report describes 2 cases of SPM managed at University Hospital Hamburg-Eppendorf during the period 2000 to 2001. Spontaneous pneumomediastinum should be considered whenever there are anamnestic data for retrosternal chest pain that radiates to the neck or back accompanied by dysphagia, dysphonia, dyspnea, and a positive Hamman's sign.
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Introduction
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Pneumomediastinum, or mediastinal emphysema, is the presence of air in the mediastinum. The disorder occurs spontaneously due to a predisposing lung disease, trauma, or surgical procedure. Spontaneous pneumomediastinum (SPM) is an infrequent, benign, and self-limiting condition that predominantly affects young males (13 to 35 years) and pregnant females. The primary presenting symptoms include retrosternal chest pain with radiation to the neck or back, dysphagia, dysphonia, and dyspnea. The clinical findings are subcutaneous emphysema, the absence of cardiac dullness to percussion, and Hamman's sign. Initially it is important to distinguish pneumomediastinum from conditions with similar clinical findings that require immediate treatment, such as cardiac tamponade, angina pectoris, pericarditis, dissecting aortic aneurysm, mediastinitis, and pulmonary embolism. Pulmonary embolism, amniotic fluid embolism, and pneumothorax are diagnostic considerations that can be ruled out because no case of pneumomediastinum coexisting with embolic disorders has been reported. In extreme circumstances, usually with severe vomiting, a ruptured esophagus can result in pneumomediastinum (Boerhaave syndrome). However, such a patient would be seriously ill, in shock, and may have a left pleural effusion. A benign clinical course and negative esophagogram can exclude this diagnosis. When SPM is positively diagnosed only conservative treatment is required, as symptoms rarely recur. This report describes 2 cases of SPM managed at University Hospital Hamburg-Eppendorf during the period 2000 to 2001.
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Case reports
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Patient 1
A 24-year-old man was admitted to the emergency room with the chief complaint of sharp chest pains. He reported the acute onset of symptoms after an episode of retching without vomiting. The recorded medical history was unremarkable. Physical examination revealed a healthy young man in no obvious respiratory distress. The chest examination revealed inspiratory and expiratory crackles. Laboratory findings showed increased inflammatory values, but all other routine variables were within the normal range. Chest roentgenogram demonstrated subcutaneous emphysema over both chest walls as well as a pneumomediastinum (Fig 1). Computed tomographic scan of the thorax revealed liquid around the esophagus and air bubbles in the mediastinum (Fig 2). Further investigation (bronchoscopy, esophagogastroscopy) ruled out any involvement of the trachea and the upper gastrointestinal tract. The patient was admitted and treated with antibiotics owing to the elevated inflammatory values. During a 6-day hospital stay the emphysema regressed and the laboratory values decreased. He was found to be asymptomatic at the 1-month follow-up examination.
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Fig 2. Transverse contrast-enhanced computed tomographic scan at admission showing air bubbles in the mediastinum (arrows) due to the spontaneous pneumomediastinum.
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Patient 2
A 30-year-old woman was referred to the emergency room with a sudden onset of thoracic and cervical swelling. She reported pain in the midsternal region and a mild worsening of resilience. A common cold had developed 2 weeks before admission. There was no history of prior medical problems. Subcutaneous emphysema over both chest walls and the neck was found during physical examination. Findings of cardiac examination were unremarkable, and the lungs were bilaterally clear. Laboratory findings were normal. Radiography of the chest demonstrated a pneumomediastinum. Emphysema of the lung and rupture of the esophagus were ruled out by a computed tomographic scan and endoscopy. The peak inspiratory flow rate was mildly reduced but arterial blood gas values were within the normal range. The patient was admitted for observation. Computed tomographic scan of the thorax showed a total resolution of the pneumomediastinum after 8 days. Follow-up was uneventful.
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Comment
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According to Gordon [1], pneumomediastinum was first reported in 1618 when Louise Bourgeois, midwife of the French royal family, observed a case of subcutaneous emphysema in a woman after labor. The first contemporary report of SPM was described by Louis Hamman described the in the "Sewall Lecture" (1939). He described the unmistakable sign (Hamman's sign) characterized by a "curious loud bubbling, crackling sound synchronized with the heart beat" [2].
Spontaneous pneumomediastinum is often referred to as respiratory pneumomediastinum, because in most of the cases it is caused by leakage of air from the respiratory tract. The leakage results from wall ruptures of marginal pulmonal alveoli, secondary to high intraalveolar pressure caused by factors such as artificial ventilation, coughing, or straining. Macklin and Macklin [3] further proposed that a pressure gradient, existing between the periphery of the lung and the hilus, leads to air dissection along the vascular sheet to the hilum. The gas spreads out along the bronchovascular trunks or within the lymphatics to the mediastinum. Interstitial emphysema and pneumomediastinum of nonpulmonary origin has also been observed in cases where air dissects into the mediastinum from the retroperitoneum or from the deep fascial planes of the neck. Respiratory SPM commonly results from prolonged Valsalva maneuver during labor and childbirth [4, 5], inhalation of drugs (crack, cocaine) [6], or as a result of mechanical airway obstruction.
Diagnosis includes physical examination and plain chest roentgenogram, and in some questionable cases thorax computed tomographic scan [7]. The initial differential diagnosis includes musculoskeletal, pleural, pulmonary, cardiac-related, and esophageal causes. Mediastinal emphysema associated with esophageal disruption carries substantial morbidity and mortality [8]. Consequently, the initial investigation should include a meglumine diatrizoate (Gastrografin; Schering Deutschland GmbH, Berlin, Germany) esophagogram. If this method fails to demonstrate extravasation, diluted barium can be used. Diagnostic endoscopy should be performed only in patients in whom esophageal perforation is highly suspected. If esophageal disruption is discovered, most patients will need surgical intervention.
Spontaneous pneumomediastinum is an infrequent condition predominantly affecting young males and pregnant females. SPM should be considered when there are anamnestic data for retrosternal chest pain radiating to the neck or back, dysphagia, dysphonia, dyspnea, and positive Hamman's sign, and when there are signs of subcutaneous emphysema in the chest and neck region. Firstly, perforation of a hollow organ (eg, esophagus, trachea), either traumatic or iatrogenous, has to be excluded by native abdominal roentgenogram or Gastrografin esophagogram. Secondly, traumatic affections (eg, blunt chest trauma, thoracic perforation) have to be ruled out. The diagnostic procedure of SPM includes physical examination and plain chest roentgenogram. Thirdly, there is no real necessity for endoscopic procedures in uncomplicated cases. Computed tomographic scan of the thorax and bronchoscopy are required in patients with a complicated clinical course or a medical history of pulmonal or thoracic disorders. Lastly, when perforation of the hollow organ is ruled out and SPM is diagnosed, only conservative treatment is required. Treatment consists of a conservative prescription of 100% oxygen by nonrebreathing face mask, analgesics, and antibiotics in cases with elevated inflammatory values.
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References
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- Gordon C.A. Respiratory emphysema in labour. Am J Obstet Gynecol 1927;14:633-638.
- Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1-21.
- 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: interpretation of clinical literature in light of laboratory experiment. Medicine 1944;23:281-358.
- Gemer O., Popescu M., Lebowits O., Segal S. Pneumomediastinum in labor. Arch Gynecol Obstet 1994;255:47-49.[Medline]
- Karson E.M., Saltzman D., Davis M.R. Pneumomediastinum in pregnancy: two case reports and a review of the literature, pathophysiology and management. Obstet Gynecol 1984;64(Suppl):39-43.
- Haines J.D., Chop W.M., Swyden S.N. Spontaneous pneumothorax, pneumomediastinum and pneumopericardium in a 16-year-old drug-abusing motorcyclist surrounded by a pack of coyotes. Postgrad Med 1989;86:79-80.
- 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 1999;67:408-411.
- Gaa J., Deininger H.K. Die spontane Ösophagusruptur-Boerhaave-Syndrom. Klin Diagn Radiol 1989;29:371-376.
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Abstract
Introduction
