Asian Cardiovasc Thorac Ann 2006;14:e9-e11
© 2006 Asia Publishing EXchange Ltd
Spontaneous Cervical Emphysema and Pneumomediastinum in an 18-year-old Woman
Navid Madershahian, MD,
Michael Meyn, MD,
Justus T Strauch, MD,
Thorsten Wahlers, MD
Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller University, Jena, Germany
For reprint information contact: Navid Madershahian, MD Phone: 49 3641 932 2989 Fax: 49 3641 932 2902 Email: Navid.Madershahian{at}med.uni-jena.de, Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller University Jena, Erlanger Allee 101, Jena 07740, Germany.
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ABSTRACT
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Pneumomediastinum or mediastinal emphysema is a known complication of traumatic injury or disease whereas spontaneous pneumomediastinum remains a rare clinical entity. We present the case of a young woman with a diagnosis of spontaneous pneumomediastinum combined with cervical emphysema without any precipitating factors or disease.
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INTRODUCTION
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Spontaneous cervical and mediastinal emphysema are multiple causal entities. It usually occurs in young people without apparent precipitating factors or disease.1 Males are reportedly more frequently affected. spontaneous pneumomediastinum (SPM) occurs secondary to alveolar rupture in the pulmonary interstitium. It emerges whenever air escapes into the perivascular connective tissue, with subsequent dissection into the mediastinum. Air may then enlarge into the visceral, retropharyngeal, and subcutaneous spaces of the neck, along the layers of the deep cervical fascia. The precipitating factor is a high intrathoracic pressure effected by cough, forced swallowing or acute effort such as extended, intense sports activity.2 Furthermore, SPM associated with the use of inhaled drugs (cocaine and cannabis) and self-induced oral injury are known to occur. Spontaneous pneumomediastinum has also been reported as a rare complication of esophageal rupture during hyperemesis gravidarum and as a complication of anorexia nervosa with affected lung mechanics and altered adipose tissue due to malnutrition. Finally, an exacerbation of bronchial asthma is a described cause of SPM.3–4 Spontaneous pneumomediastinum is a rare, mostly self-limited disorder, usually considered in young adults presenting without serious underlying pulmonary disease. We report a case of a young adult woman with combined SPM and cervical emphysema without apparent precipitating factors or disease.
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CASE REPORT
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An 18-year-old female was admitted to the emergency room (ER) complaining of mild shortness of breath, discomfort on swallowing and a sensation of fullness and retrosternal pressure. There was no history of intentional or unintentional Valsalva maneuver, positive pressure ventilation, or breath compressing gases. The non-smoking patient had not experienced any episodes of acute shortness of breath, vomiting or forced swallowing. Anamnestically no drugs had been used. The patient was not an asthmatic and gave no history of recent throat or chest trauma. No extended sports activities were reported.
Physical examination findings were moderate tachypnea (25 breaths·min–1) and a heart rate of 95 beats·min–1. The patient was afebrile and normotensive with a blood pressure of 120/70 mm Hg. Pulse oxymetry recorded an oxygen saturation of 98% O2 on room air. Her height was 165 cm and weight was 59 kg. Chest percussion, breathing sounds and breathing movements were normal. There was no pericardial rub or crunch on auscultation. A complete blood count revealed a white blood cell count of 12,000·µL–1, a hemoglobin of 8.9 mmol·L–1, a hematocrit of 41% and a platelet count of 310 Gpt·L–1. Blood chemistry findings were within normal limits. The examination was otherwise unremarkable.
The accompanying cervical X-Ray revealed the presence of air within the soft tissues of the neck. There was no radiological evidence of pneumothorax or pleural effusion. An esophagogram, otolaryngologic examination, bronchoscopy and esophagoscopy were carried out and revealed no pathological findings. A computerized tomography (CT) scan with oral contrast confirmed esophageal integrity and revealed peritracheo-esophageal emphysema. The CT scan of the cervical region demonstrated emphysema continuing cephalad to the retropharyngeal space (Figure 1
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Figure 1. Computerized tomography showing spontaneous cervical emphysema (A) and pneumomediastinum (B) on admission.
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Conservative treatment consisted of bed rest and nasal application of 4L of oxygen whilst awaiting absorption of the mediastinal air. Antibiotic therapy was administered to prevent mediastinitis. The patient’s symptoms continued to resolve over the next days and she remained afebrile and clinically stable. At 4 days post admission the patient was free of clinical symptoms and was discharged well. No underlying disease was found in this case. At 1 week follow-up, the patient was asymptomatic and a repeated CT scan was normal (Figure 2).
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Figure 2. Computerized tomography performed one week later showing normal mediastinal structures after air resorption without any treatment.
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DISCUSSION
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Spontaneous pneumomediastinum was first described by Hamman in 1939. Hamman’s signs consisted of crackles, noise of air bursting bubbles, or churning sounds that varied with the heartbeat on auscultation of the precordium,5 whereas the first description of pneumomediastinum was attributed to Laennec in 1819 in the context of chest trauma.6
This reported case confirms that SPM is generally a benign condition with a self-limited course occurring usually in healthy young patients without serious underlying pulmonary disease. Spontaneous pneumomediastinum is more frequently seen in men than women. Its incidence ranges widely in the published literature and is difficult to estimate as it is frequently unrecognised or asymptomatic. As SPM occurs in 1 per 7,000 to 42,000 hospital admissions, it seems likely that SPM is under-diagnosed by 30% or more in clinical practice. Kaneki and associates demonstrated that nearly 30% of patients with mild SPM could not be detected by chest X-Ray and that chest CT scan was required to confirm a diagnosis in these patients.7 Further diagnostic procedures such as esophagogram, esophagoscopy, and bronchoscopy are performed following conventional radiographic imaging to rule out spontaneous (Boerhaave Syndrome) or traumatic rupture of the esophagus and tracheobronchial tree, among different causes of secondary pneumomediastinum. Surgical relief is unnecessary, as subcutaneous air resolves spontaneously. Recurrence of SPM is rare but has been reported.
Whilst some patients with SPM may be asymptomatic, main symptoms reported in the literature are retrosternal chest pain, usually radiating to the neck, back or shoulders, subcutaneous emphysema, dyspnea, Hamman’s sign, dysphagia and back pain. The natural pathophysiology of SPM can make it a potentially life threatening emergency depending on the size of free air in the mediastinum. Esophageal rupture, necrotizing mediastinitis, unvented mediastinal or pulmonary adventitial air causing venous impairment must be excluded. These patients require aggressive investigation and management.
In summary, SPM is a rare and mostly benign condition which can be managed conservatively. Treatment of SPM should consist of reassuring the patient, bed rest, analgesia and sedatives when needed. Spontaneous pneumomediastinum should be considered as a differential diagnosis in chest pain, especially in healthy young adults.
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REFERENCES
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- Gerazounis M, Athanassiadi K, Kalantzi N, Moustardas M. Spontaneous pneumomediastinum: a rare benign entity. J Thorac Cardiovasc Surg 2003;126:774–6.[Abstract/Free Full Text]
- Jougon JB, Ballester M, Delcambre F, Mac Bride T, Dromer CE, Velly JF. Assessment of spontaneous pneumomediastinum: experience with 12 patients. Ann Thorac Surg 2003;75:1711–4.[Abstract/Free Full Text]
- Abolnik I, Lossos IS, Breuer R. Spontaneous pneumomediastinum. A report of 25 cases. Chest 1991;100:93–5.[Abstract/Free Full Text]
- Pittman JA, Pounsford JC. Spontaneous pneumomediastinum and ecstasy abuse. J Accid Emerg Med 1997;14:335–6.[Abstract/Free Full Text]
- Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1–21.
- Laennec RTH. Treatise on diseases of the chest and on mediate auscultation. Translated by John Forbes. 2nd Edition. London: T&G Underwood. 1819.
- 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;67:408–11.[Medline]
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ABSTRACT
INTRODUCTION
