Pneumomediastinum: ingrijpen is niet altijd vereist
Open

Klinische les
06-10-2015
Herman J.A. Zandvoort, Hidde M. Kroon, Stephanie C.E. Schuit en Bas P.L. Wijnhoven

Pneumomediastinum: intervention is not always necessary

This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.

Introduction

Pneumomediastinum is characterized by the presence of free air in the mediastinum. This can be a sign of a severe underlying disorder that requires urgent intervention. However, pneumomediastinum is also associated with other causes that can be treated conservatively. Here, we describe three patients who presented with a primary or spontaneous pneumomediastinum and a secondary pneumomediastinum due to traumatic or iatrogenic perforation.

Case description

Patient A, a healthy 28-year-old male presented at the emergency department with left sided thoracic pain since 1 day. The pain started a few hours after his work as a climbing instructor. A chest X-ray did not show any abnormalities and an additional computed tomography (CT) of the chest to exclude pulmonary embolism showed a pneumomediastinum with air configurations around the left lung hilum. It was considered as spontaneous pneumomediastinum, possibly caused by the strenuous physical activity during his work. He was admitted to the hospital for observation and treated with analgesics.

Patient B, a 75-year-old female presented at the emergency department after two times of forceful vomiting and with chest pain. Since the chest X-ray did not show any abnormalities, a CT scan of the chest was performed. This showed a pneumomediastinum and a left sided hydropneumothorax. Because of the history of forceful vomiting Boerhaave’s syndrome was suspected. At esophagoscopy a longitudinal transmural defect was seen in the distal esophagus and a self expandable stent was placed to cover the defect. A chest drain was inserted in the left pleural cavity to treat the hydropneumothorax. The course was complicated by the development of a pleural empyema which required a thoracotomy.

Patient C, a 25-year-old male with a history of type 1 diabetes and alcohol and cocaine abuse was admitted to the emergency department with a decreased level of consciousness since two days. During the previous days he consumed a lot of alcohol, smoked cannabis and inhaled cocaine through the nose. At physical examination subcutaneous emphysema was palpable in the neck. His blood glucose concentration was 1.9 mmol / l. Chest X-ray confirmed the presence of subcutaneous air and also showed a pneumomediastinum. There were no additional findings on CT scan, esophagoscopy and bronchoscopy. Working diagnosis was a hypoglycemic coma and the patient was admitted to the intensive care unit. The spontaneous pneumomediastinum was likely caused by the intranasal use of cocaine and was treated conservatively.

Conclusion

Recognition of the underlying cause of pneumomediastinum is essential for further diagnostic studies and patient management. Unnecessary investigations and interventions, which may cause further harm to and hospitalization of the patient, can thereby be prevented.