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Journal of Cardiothoracic Surgery
Open Access
Research article
Spontaneous pneumomediastinum: diagnostic and therapeutic
interventions
Faisal Al-Mufarrej*
1
, Jehangir Badar
1
, Farid Gharagozloo
1,2
,
Barbara Tempesta
2
, Eric Strother
1
and Marc Margolis
1,2
Address:
1
The George Washington University Medical Center, Department of Surgery, 2300 Eye Street NW, Washington, DC 20037, USA and
2
Washington Institute of Thoracic and Cardiovascular Surgery, 2175 K Street NW, Washington DC 20037, USA
Email: Faisal Al-Mufarrej* - [email protected]; Jehangir Badar - [email protected]; Farid Gharagozloo - [email protected];
Barbara Tempesta - [email protected]; Eric Strother - [email protected]; Marc Margolis - [email protected]
* Corresponding author
Abstract
Objectives: The objective of this case series is to review our experience with spontaneous
pneumomediastinum, review the available literature, and refine the current clinical approach to this
uncommon condition.
Methods: The case notes of all patients admitted to the George Washington University Medical
Center with spontaneous pneumomediastinum from April 2005 to June 2008 were retrospectively
reviewed, indentifying seventeen patients on whom various data was collected and analyzed.
Results: The typical patient is a young man. The commonest presenting complaint is chest pain.
Odynophagia and subcutaneous emphysema are common. Leucocytosis is uncommon. The need
for swallow studies, antibiotics, and prolonged hospitalization is uncommon. Most patients have no
recurrences or sequelae on long-term follow-up.
Conclusion: Spontaneous pneumomediastinum is an uncommon, self-limiting condition. Due to
concerns for the integrity of the aero-digestive tract, the finding of spontaneous
pneumomediastinum usually results in unnecessary radiological investigations, dietary restriction
and antibiotic administration with prolonged hospitalization.
Introduction
Pneumomediastinum or air in the mediastinum may orig-
inate from the esophagus, lungs, or bronchial tree. As sug-
gested by a handful of small case series in the literature [1-
4], spontaneous pneumomediastinum is an uncommon,
self-limiting condition. It results from alveolar rupture-
otherwise known as the Macklin phenomenon. Alveolar
rupture results from high intra-alveolar pressures, low
peri-vascular pressures, or both. Air escaping from the
alveoli tracks into the mediastinum during the breathing
cycle as the pressure in the mediastinum decreases relative
the pulmonary parenchymal pressure. From there, air may
track into the cervical subcutaneous tissues, epidural
space [5], pericardium [6], and/or peritoneal cavity [7,8].
Spontaneous pneumomediastinum usually results from
bronchial hyper-reactivity or barotraumas. Bronchial con-
striction may be due to asthma or inhalation [8] of toxic
agents (e.g. cocaine) [9]. Barotrauma may occur with
instrumentation, mechanical ventilation, or Valsalva's
Published: 3 November 2008
Journal of Cardiothoracic Surgery 2008, 3:59 doi:10.1186/1749-8090-3-59
Received: 29 August 2008
Accepted: 3 November 2008
This article is available from: http://www.cardiothoracicsurgery.org/content/3/1/59
2008 Al-Mufarrej et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Cardiothoracic Surgery 2008, 3:59 http://www.cardiothoracicsurgery.org/content/3/1/59
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maneuver (expiration through resistance) that occurs with
straining (e.g. during labor) or vomiting [5]. The finding
of a pneumomediastinum usually places the integrity of
the thoracic aero-digestive tract into question resulting in
unnecessary radiological investigations, needless dietary
restriction, unjustified antibiotic administration, and pro-
longed hospitalization.
The objective of this retrospective study is to review our
experience with spontaneous pneumomediastinum,
review the available literature, and refine the current clin-
ical approach to this uncommon condition.
Methods
We retrospectively reviewed the case notes of all patients
admitted to George Washington University Hospital with
pneumomediastinum from April 2005 to June 2008. All
trauma patients as well as patients with intra-thoracic
malignancy, hemodynamic instability, or recent aero-
digestive instrumentation were excluded from the study.
Seventeen patients with spontaneous pneumomediasti-
num were identified.
For each case, data was collected regarding demographics,
likely etiology, presenting complaints, white cell count
level, other laboratory abnormalities, findings on chest x-
ray and computed axial tomography, results of any con-
trast swallow study or esophagogastroduodenoscopy
done, use of antibiotics, dietary restriction, length of hos-
pitalization, and condition on follow-up.
The Institutional Review Board of the George Washington
University approved this retrospective study (IRB number
060818).
Results
There were eleven men (65%) and six women (35%). The
mean age was 25.5 years (range 1939 years). The etiol-
ogy was unclear in 29.4% of patients. Asthma and alco-
hol-related emesis were implicated in 23.5% of patients
each, while physical activity and gastro-intestinal disease
(including gastroparesis and history of ulcer disease) were
seen in 11.8% of cases each. Cocaine and history of pneu-
mothorax were noted in only 5.9% of patients each.
The commonest presenting complaint was chest pain
(usually retrosternal) and dyspnea (frequency of 58.8%
and 41.2%, respectively). 11.8% of patients presented
with neck pain and 17.8% of them noted some degree of
odynophagia. Less common symptoms included nausea/
emesis (11.8%), back pain (11.8%), abdominal pain
(5.9%) and fever (5.9%). None of the patients had true
complaints of dysphagia. Only 11.8% had cervical subcu-
taneous emphysema on exam.
With the exception of one dehydrated patient with pre-
renal acute renal failure and a white cell count of 19.6
10
9
/L, the white cell count ranged from 4.9710.86 10
9
/
L with an average white cell count of 9.42 10
9
/L. D-
dimer levels were checked in all patients with chest pain
and were found to be abnormal in 11.8% of cases with a
range of 640700 ng/ml.
The pneumomediastinum was visible of chest x-ray on
52.9% patients (33.3% of females and 63.6% of males),
but none of the patients had any effusions noted on their
chest x-rays. The pneumomediastinum resolved on chest
x-ray in 26 days with an average of 3.5 days. Computed
axial tomography (CT) of the chest was done in all
patients but one. The finding of pneumomediastinum on
computed axial tomography was associated with subcuta-
neous emphysema in 41.2%, pneumoperitoneum in
5.9% and pneumorachis in another 5.9%. A contrast swal-
low was done in 58.8% patients, all of which were nega-
tive. An esophagogastroduodenoscopy (EGD) with the
finding of distal esophagitis was done during the same
admission or soon after discharge on patients with gas-
trointestinal disease.
53% of cases were initially admitted to the intensive care
unit for observation, while 47% were admitted to the sur-
gical floor with 4-hourly vitals. For patients with no other
co-morbidities, the length of hospital stay ranged from
2372 hours (average of 40.5 hours). Patients admitted
with significant dehydration, asthma exacerbation, or
drug intoxication had longer hospital stays (511 days
with average of 7 days).
Broad spectrum intravenous antibiotics were adminis-
tered in the emergency room in 58.8% patients, 70% of
whom continued to receive antibiotics during their hospi-
talization. The antibiotics used were variable and
included various combinations of ciprofloxacin, clin-
damycin, moxifloxacin, piperacillin-tazobactam,
cefepime, and metronidazole. 52.9% of the patients were
made nil per os upon admission and advanced to regular
diet in 2448 hrs. The remaining patients were allowed to
have a regular diet after a contrast swallow study had con-
firmed an intact esophagus.
Follow-up ranged from 6 days to 34 months with a mean
follow-up of 6.72 months. All patients were asympto-
matic with normal chest x-rays on follow-up.
Discussion
Pneumomediastinum is an uncommon self-limiting
benign condition that is frequently over-investigated and
over-treated due to concern for missing an aero-digestive
injury. A handful of small case series in the literature have
suggested the benign course of this condition [1-4], but
Journal of Cardiothoracic Surgery 2008, 3:59 http://www.cardiothoracicsurgery.org/content/3/1/59
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there are still not clear guidelines regarding the diagnostic
and therapeutic interventions needed for patient with
spontaneous pneumomediastinum. Our experience with
spontaneous pneumomediastinum suggests limiting the
use of swallow studies, antibiotics, and dietary restriction
to allow for early discharge and better use of hospital
resources.
We suggest that a complete blood count and a CT of the
chest for all patients. Even for patients with obvious pneu-
momediastinum on chest x-ray, a CT the chest with intra-
venous contrast should be obtained since chest x-rays are
obviously not sensitive at picking up mild disease or eval-
uating the chest for pathology. An elevated D-dimer may
occur in patient with benign pneumomediastinum in the
absence of thromboembolic disease, but leucocytosis is
unusual in such patients.
Not all patients with spontaneous pneumomediastinum
need contrast swallow studies. A contrast swallow study
should be obtained for patients with emesis, dysphagia,
gastro-intestinal disease, trauma, hemodynamic instabil-
ity, fever, leucocytosis, pleural effusion, or pneumoperito-
neum. While esophageal rupture (Boerhaave's syndrome)
is classically described with left-sided pleural effusions,
one must be suspected esophageal injury in the presence
of any pleural effusion whether it is left or right-sided
[10,11]. The classic Meckler's triad of esophageal rupture
includes vomiting, lower chest pain, and cervical subcuta-
neous emphysema following overindulgence in food or
alcohol. Our experience, however, demonstrates that both
cervical subcutaneous emphysema and odynophagia are
quite common in the setting of benign spontaneous
pneumomediastinum, and that patients with either find-
ing do not need an esophageal evaluation.
This case series clearly suggests that not all patients with
emesis and pneumomediastinum (even those with pneu-
moperitoneum) have Boerhaave's syndrome. This is con-
firms the findings of a recently published small case series
in the literature [12]. The mechanism of the pneumome-
diastinum is likely due to alveolar rupture secondary to
the significant Valsalva maneuver that accompanies the
vomiting reflex. The pneumomediastinum in this setting
is likely benign; however, a swallow study should be done
in all cases presenting with emesis. Given the gravity of
delayed diagnosis of esophageal rupture, the index of sus-
picion must be high in cases of pneumomediastinum
with the right mechanism for rupture (emesis or trauma).
Esophageal rupture has also been described in patients
presenting primarily with hematemesis [13]. It is impor-
tant to suspect esophageal injury in such cases even in the
absence of other signs of rupture (fever, leucocytosis,
hemodynamic instability, pleural effusion) since early
contained esophageal perforations may be subclinical and
hard to recognize [13,14]. This is especially true for
immunocompromised patients or ones on steroids or
antibiotics.
For patients with negative swallow studies, patients can be
admitted for 23 hour observation with no need to keep
them nil per os. For patients who do not undergo an eval-
uation of their esophagus, they should be kept nil per os
only overnight with advancement to regular diet the very
next day as long as the white cell count remains below 11
10
9
/L. Intensive care is unnecessary unless patient is
hemodynamically unstable or the diagnosis of esophageal
injury is highly suspected. Slow diet advancement and
holding up discharge until chest x-ray resolution of pneu-
momediastinum prolongs hospitalization with no differ-
ence in long term outcome. In addition to the contrast
swallow study, patients with known gastro-intestinal dis-
ease (gastroparesis, gastro-esophageal reflux, peptic ulcer
disease, etc.) who present with pneumomediastinum
need an EGD in the in-patient or out-patient setting in
order to evaluate the esophagus and stomach for inflam-
matory and ulcer disease.
There is no need for intravenous antibiotics in patients
with negative swallow studies, and in patients who do not
undergo an evaluation of their esophagus, antibiotics may
mask an occult injury. All patients did well regardless of
whether they obtained antibiotics or not, suggesting
against the use of antibiotics in this patient population.
Conclusion
Our experience with spontaneous pneumomediastinum
confirmed the previously reported benign nature of this
uncommon condition. While prospective studies or meta-
analyses in this subject matter are clearly needed, this case
series does suggest that the condition is over-investigated
and over-treated. Thus, clinicians need to be more judi-
cious with the use of hospital resources in managing
patients with spontaneous pneumomediastinum.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
FM, JB, MM, FG, ES, and BT were all involved the care of
the patients included in the study. FM, ES and BT collected
the data. FM and JB did the background literature search
and drafted the manuscript. MM and FG were involved in
the conception of the study and the critical review of the
intellectual content of the manuscript. All authors read
and approved the final manuscript.
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