CASE 4924 Published on 04.06.2008

Spontaneous Pneumomediastinum

Section

Chest imaging

Case Type

Clinical Cases

Authors

Tziafalia C., Tsimitselis G., Fezoulidis I. Department of Radiology, University Hospital of Larissa, Greece, Feidiou 1, 43 100 Karditsa, xtziaf@mycosmos.gr

Patient

25 years, male

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Clinical History

A 25-year-old man presented in shock and previous mild epigastric pain and dyspnea

Imaging Findings

A 25-year-old man was referred to our clinic in shock of unknown explanation. A few hours previously he had complained of mild dyspnea and epigastric pain. There was no previous history of illness or trauma. On antero-posterior chest x-ray there was no evidence of free air in the mediastinum. Computed tomography scanning of the mediastinum showed air around the descending aorta, esophagus, trachea and in the anterior mediastinum.Barium swallow showed no evidence of esophageal rupture. The patient recovered fully and he was discharged home 6 days after his admission.

Discussion

Spontaneous pneumomediastinum is a a benign condition diagnosed rarely in patients below the age of 18 years. The incidence is difficult to evaluate because the disease frequently is unrecognized. Its incidence ranges from 1 in 800 to 1 in 42,000 patients presenting at hospital emergency units. The pathophysiology consists of an increased pressure gradient between the intraalveolar and interstitial spaces enhances air leakage from small alveolar openings and ruptured alveoli into the perivascular adventitia causing interstitial emphysema. Acute onset of chest pain is the usual clinical presentation. A single chest x-ray usually is sufficient to make the diagnosis of this entity. Anteroposterior chest radiographs typically show a vertical lucent line along the left side of the heart and aortic arch, showing the pleura as a fine opaque line. CT is useful, because the anatomic location of the air may be discovered on cross-sectional display. Especially air can be found around the great vessels of mediastinum, esophagus and trachea. Barium swallow is always indicated to eliminate esophageal perforation and to rule out the presence of a radiotransparent foreign body. Generally, spontaneous pneumomediastinum is self limiting. Analgesics, bed rest, and treatment for coughing are appropriate The air usually reabsorbs within a few days.

Differential Diagnosis List

Spontaneous pneumomediastinum in absence of oesophageal or other pathology.

Final Diagnosis

Spontaneous pneumomediastinum in absence of oesophageal or other pathology.

References

[1] Assessment of spontaneous pneumomediastinum: experience with 12 patients.
Jougon JB, Ballester M, Delcambre F, Mac Bride T, Dromer CE, Velly JF.
Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University Hospital, Pessac, France. Ann Thorac Surg. 2003 Jun;75(6):1711-4. (PMID: 12822604)

[2] Atypical presentation of spontaneous pneumomediastinum.
Ralph-Edwards AC, Pearson FG. Division of Thoracic Surgery, University of Toronto, Ontario, Canada. Ann Thorac Surg. 1994 Dec;58(6):1758-60. (PMID: 7979754)

[3] Non-traumatic thoracic emergencies: acute chest pain: diagnostic strategies.
Bonomo L, Di Fabio F, Rita Larici A, Merlino B, Luigia Storto M. Department of Radiology, University of Chieti. Eur Radiol. 2002 Aug;12(8):1872-85. (PMID: 12136307)

[4] Idiopathic Spontaneous Pneumomediastinum: An Uncommon
Emergency in Children, By J. Nounla, R.B. Tro¨ bs, J. Bennek, and I. Lotz
Leipzig, Germany, J Pediatr Surg 2004, 39:E7. (PMID: 15136999)

[5] Spontaneous pneumomediastinum: A rare benign entity, Gerazounis M., Athanassiadi K., Kalantzi N.,Moustardas M, J Thorac Cardiovasc Surg. 2003 Sep;126(3):774-6. (PMID: 14502153)

[6] Spontaneous pneumomediastinum: is a chest X-ray sufficient? Gardikis S, Tsalkidis A, Limas C, Antypas S, Manavis I, Chatzimicael A, Arvanitidou V, Simopoulos C. Minerva Pediatr. 2003 Jun;55(3):293-6. (PMID: 12900716)

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