Disorders of the Pleura |

Spontaneous Pneumomediastinum FREE TO VIEW

Vanessa Yap, MD; Debapriya Datta, MD
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University of CT Health Center, Farmington, CT

Chest. 2014;145(3_MeetingAbstracts):265A. doi:10.1378/chest.1835826
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SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Spontaneous pneumomediastinum (SPM) is an unusual condition. It is reported to present in one in 1,000 to one in 40,000 ED referrals. It is characterized by the presence of interstitial air in the mediastinum without any apparent precipitating factor. It is seen after intrathoracic pressure changes leads to alveolar rupture and dissection of air along the tracheobronchial tree. We report a case of a young male who presented with a spontaneous pneumomediastinum.

CASE PRESENTATION: A 19-year old healthy male, with no significant past medical history, presented to the ED with complaints of dull sub-sternal chest pain that developed while playing volley ball. There was no associated trauma. The patient denied shortness of breath, dizziness. On exam, the patient appeared to be in no distress. Vital signs were normal and lungs were clear to auscultation. Cardiac examination revealed no abnormality. Crepitus was present in the neck. Chest x-ray showed no obvious abnormality. CT scan of the chest revealed air in the mediastinum, extending to the subcutaneous neck tissues and down to the pericardium. The patient was admitted to the ICU for close monitoring. He was treated with analgesics and kept nil per orally initially till a gastrografin swallow study was performed and showed no evidence of esophageal perforation. He remained hemodynamically stable with improvement in pain and no development of respiratory symptoms. Follow-up chest x-ray over the next 2 days showed no change from his initial radiograph and the patient was subsequently discharged.

DISCUSSION: Spontaneous pneumomediastinum (SPM) is an uncommon, benign condition that often presents with chest pain or dyspnea. Despite its low incidence, SPM should be considered in the differential diagnosis of acute chest pain because it requires a high index of suspicion. It usually occurs in young men without any apparent precipitating factor or disease. It can develop without a triggering event and with no findings on chest radiography. Common presenting complaints are chest pain (54%), shortness of breath (39%), and subcutaneous emphysema (32%). Triggering events are reported to be emesis (36%) and asthma flare-ups (21%). No apparent triggering event is reported in 21% of patients. Cases of SPM caused by rapid ascent in scuba divers, Valsalva maneuvers and inhalation of cocaine, methamphetamine, ecstasy, marijuana have been reported. Chest radiograph is diagnostic in 69%; CT chest has a diagnostic rate of 100%. Patients with SPM respond well to medical treatment, with no recurrence in the majority of cases. Treatment is expectant and includes analgesia, rest, and/or initial oxygen therapy with the SPM typically reabsorbing over a period of 1-2 weeks without intervention and only rare recurrence. Because a subset of patients with SPM may have significant pathology, extensive workups are often necessary.

CONCLUSIONS: SPM is a self-limited disorder. Patients with SPM respond well to medical treatment, with no recurrence in the majority of cases. Secondary causes must be ruled out to avoid an unfavorable outcome.

Reference #1: Caceres M, Ali SZ, Braud R et al. Spontaneous pneumomediastinum: a comparative study and review of the literature.Ann Thorac Surg. 2008 Sep;86(3):962-6.

Reference #2: Koullias GJ, Korkolis DP, Wang XJ et al. Current assessment and management of spontaneous pneumomediastinum: experience in 24 adult patients.Eur J Cardiothorac Surg. 2004 May;25(5):852-5.

Reference #3: McMahon DJ. Spontaneous pneumomediastinum. Am J Surg. 1976;131:550-551.

DISCLOSURE: The following authors have nothing to disclose: Vanessa Yap, Debapriya Datta

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