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Alden McDonald, 2002 Gillian Lieberman, MD PNEUMOMEDIASTINUM: A PATIENT PRESENTATION Alden “Chip” McDonald, III Harvard Medical School, Year III Gillian Lieberman, MD November 2002

PNEUMOMEDIASTINUM: A CASE PRESENTATION

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Page 1: PNEUMOMEDIASTINUM: A CASE PRESENTATION

Alden McDonald, 2002Gillian Lieberman, MD

PNEUMOMEDIASTINUM: A PATIENT PRESENTATION

Alden “Chip” McDonald, IIIHarvard Medical School, Year III

Gillian Lieberman, MD

November 2002

Page 2: PNEUMOMEDIASTINUM: A CASE PRESENTATION

Alden McDonald, 2002Gillian Lieberman, MD

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AGENDA

I. Patient PresentationII. Diagnosis of PneumomediastinumIII. Causes of PneumomediastinumIV. Work-Up of PneumomediastinumV. Patient Wrap-Up

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Alden McDonald, 2002Gillian Lieberman, MD

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PATIENT PRESENTATION

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Alden McDonald, 2002Gillian Lieberman, MD

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HISTORY

CM is a 19 year-old pre-med Harvard College male who presented to UHS complaining of sore throat when drinking liquids and pleuritic chest pain in the superior chest radiating to the neck. Symptoms began upon awakening this morning and patient reports having several bouts of intense emesis of unknown cause (likely viral gastroenteritis) yesterday evening. Patient denies any hematemesis and denies vomiting this AM.

Source: Harvard University Health Services

Permission obtained.

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Alden McDonald, 2002Gillian Lieberman, MD

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PHYSICAL EXAM

BP- 122/72, T- 99.5General- Pt. talking clearly, in no apparent respiratory

distress.HEENT- Tenderness in the area of the cricoid. Crepitance

felt in the right supraclavicular area. Otherwise unremarkable.

Chest- Clear to auscultation bilaterally. No stridor.Heart- Regular rate and rhythm. No murmurs.

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S PA CHEST X-RAY

Air outlining ascending aorta

Air in neck tissues

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S PA CHEST X-RAY (expiration)

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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DIAGNOSIS OF PNEUMOMEDIASTINUM

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Alden McDonald, 2002Gillian Lieberman, MD

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CLINICAL SIGNS & SYMPTOMS

• Subcutaneous emphysema- crepitation in neck • Pleuritic chest pain• Neck pain• Dyspnea• Dysphagia• Hamman sign = “mediastinal crunch”• Pneumothorax

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Alden McDonald, 2002Gillian Lieberman, MD

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RADIOGRAPHIC VIEWS

• PA Chest x-ray (inspiration and expiration)• Lateral Chest x-ray• Lateral decubitus• Neck films

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Alden McDonald, 2002Gillian Lieberman, MD

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RADIOGRAPHIC SIGNS OF PNEUMOMEDIASTINUM

PA Chest X-RayStreaky radiolucencies in mediastinum (most commonly in left

paracardiac area)Air outlining mediastinal structuresContinuous diaphragm sign of Levin

Lateral Chest X-RayRetrosternal air

Lateral Decubitus Chest X-RayAir will not move with change in position

Neck FilmsAir outlining fascial planes of the neck

Page 12: PNEUMOMEDIASTINUM: A CASE PRESENTATION

Alden McDonald, 2002Gillian Lieberman, MD

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CM’S PA CHEST X-RAY (expiration)

Air outlining ascending aorta

Streaky lucencies

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S LATERAL CHEST X-RAY

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S NECK FILMS

Streaky lucencies

Contrast in hypopharynx

Aberrant air

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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COMPANION PATIENT #1- PNEUMOMEDIASTINUM ON CT

Air outside of trachea

Source: BIDMC PACS

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Alden McDonald, 2002Gillian Lieberman, MD

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PNEUMOMEDIASTINUM VS. PNEUMOTHORAX OR PNEUMOPERICARDIUM

Pneumomediastinum vs. Medial Pneumothorax• Lateral decubitus positioning will reveal change in air

distribution in pneumothorax, whereas mediastinal air will remain locked in position

• Clear delineation of intramediastinal structures in pneumomediastinum

Pneumomediastinum vs. Pneumopericardium• Lateral decubitus positioning will reveal change in air

distribution in pneumopericardium, whereas mediastinal air will remain locked in position

• Pericardial reflections do not extend above ascending aorta• Thickened pericardium in pneumopericardium can be

differentiated from mediastinal pleura

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Alden McDonald, 2002Gillian Lieberman, MD

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CAUSES OF PNEUMOMEDIASTINUM

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Alden McDonald, 2002Gillian Lieberman, MD

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DIFFERENTIAL DIAGNOSIS OF PNEUMOMEDIASTINUM

Where did the air come from?• Air from outside• Air from inside• Air from gas-producing organisms

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM OUTSIDETrauma• Gunshot wound• Stab wound• Other penetrating traumaIatrogenic• Mediastinal surgery• Mediastinoscopy• Sternal bone marrow aspiration• Thyroidectomy• Tonsillectomy

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE

4 Sources:1) Pulmonary2) Mediastinum3) Head and Neck4) Abdomen

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- PULMONARY

Increased alveolar pressure Abnormally weak lung parenchyma

Alveolar overdistention and rupture

Air leak into pulmonary interstitium

Air dissects to lung roots

Air enters mediastinum

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- PULMONARY

Increased alveolar pressure Abnormally weak lung parenchyma• Ventilation assistance (e.g. PEEP)• Airway obstruction (e.g. asthma)• Vomiting (e.g. anorexia nervosa)• Coughing• Straining (e.g. Valsalva maneuver)• Heimlich maneuver

• Infection (especially viral or TB)• Sarcoid• Emphysema• ARDS• Metastases to the lung• Needle biopsy of lung

• Blunt chest trauma • Atelectasis

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- PULMONARYRoutes of Air

(1) Air ruptures from alveolus into perivascular- peribronchial fascial sheath

(2) Fascial sheath ruptures

(3) Rupture into the pleural space may occur

(4)Mediastinal air under tension may rupture mediastinal pleuraSource: Cyrlak D, 1984

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- MEDIASTINUM

Rupture of air-containing mediastinal structures(esophagus, trachea, bronchi) caused by:

• Trauma (blunt or penetrating)

• Iatrogenic disease(intubation, tracheotomy)

• Acute increased intraluminal pressure(vomiting, childbirth, coughing, defecation, weightlifting, seizures)

• Malignancy(fistula formation)

• Spontaneous(less common)

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- HEAD & NECK

Perforation of the nasopharynx, larynx, and cervical portion of the esophagus and trachea caused by:

• Trauma (including facial fractures, especially those involving the sinuses)

• Iatrogenic disease(placement of nasogastric tube, endotracheal intubation, facial surgery, dental procedures, neck surgery)

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM INSIDE- ABDOMEN

Air extending from abnormal collections of air in the abdomen, intra- or extraperitoneal air, caused by:

• Trauma• Iatrogenic

(perforation of the bowel during gastroscopy, colonoscopy, rectal or renal surgery)

• Bowel perforation(perforation of diverticula, gastric or duodenal ulcers)

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Alden McDonald, 2002Gillian Lieberman, MD

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AIR FROM GAS-PRODUCING ORGANISMS

• Acute infection of the mediastinum causing mediastinitis is rare.

• Retroperitoneal infections may introduce gas into the soft tissues, which spreads to mediastinum.

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Alden McDonald, 2002Gillian Lieberman, MD

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WORK-UP OF PNEUMOMEDIASTINUM

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Alden McDonald, 2002Gillian Lieberman, MD

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ASSESS FOR UNDERLYING ILLNESSWork-up is predicated on underlying illness that may have caused

pneumomediastinum. Recall differential diagnosis:

• Air from outsideAssess defects from trauma or iatrogenic sources

• Air from insidePulmonary- Address causes of increased alveolar pressure or abnormally weak pulmonary parenchymaMediastinum- Contrast medium swallow to rule-out esophageal perforation (water-soluble contrast agent); Endoscopy, bronchoscopy if indicatedHead & Neck- Assess perforations from trauma/iatrogenic sourcesAbdomen- Evaluate source of abnormal air in the abdomen

• Air from gas-producing organismsAssess and treat infection

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Alden McDonald, 2002Gillian Lieberman, MD

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ASSESS FOR POSSIBLE COMPLICATIONS/ PROGRESSION

Serious Complications:• Tension pneumothorax• Tension pneumopericardium• Mediastinitis

Follow-up chest x-ray within 12-24 hours to detect any progression or complications.

May admit for observation.

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Alden McDonald, 2002Gillian Lieberman, MD

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PROGNOSIS

• Prognosis depends on underlying illness and complications.

• Generally good prognosis.• Pneumomediastinum and symptoms usually

resolve in 2-7 days.

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Alden McDonald, 2002Gillian Lieberman, MD

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PATIENT WRAP-UP

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S GASTROGRAFFIN SWALLOW ONE DAY LATER

No esophageal perforation

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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COMPANION PATIENT #2- ABNORMAL GASTROGRAFFIN/BARIUM SWALLOW

Leakage of contrast

Source: BIDMC PACS

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Alden McDonald, 2002Gillian Lieberman, MD

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CM’S CHEST X-RAY ONE DAY LATER

Pneumomediastinum still present, but not expanding

Source: Harvard University Health Services

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Alden McDonald, 2002Gillian Lieberman, MD

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OUTCOME

• CM’s symptoms resolved one day later, although a pneumomediastinum remained visible yet stable on the chest x-ray.

• CM was never admitted to the hospital but was told to return to the clinic if symptoms continued.

• CM has never had any problems since and is now in his third year of medical school.

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Alden McDonald, 2002Gillian Lieberman, MD

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SUMMARYI. Patient Presentation

CM demonstrated clinical and radiographic signs and symptoms of pneumomediastinum

II. Diagnosis of Pneumomediastinum- Clinical signs and symptoms including crepitance, pleuritic chest pain, neck pain, dyspnea- Radiographic signs on PA, lateral, lateral decubitus chest x-rays, neck films, CT

III. Causes of Pneumomediastinum- Air from outside- Air from inside (pulmonary, mediastinal, head & neck, abdomen)- Air from gas-producing organisms

IV. Work-Up of Pneumomediastinum- Assess underlying illness- Monitor for complications and progression

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Alden McDonald, 2002Gillian Lieberman, MD

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ACKNOWLEDGEMENTS

• Daniel Saurborn, MD• Gillian Lieberman, MD• Pamela Lepkowski• Michael Larson• Harvard University Health Services• Larry Barbaras and Cara Lyn D’amour

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REFERENCESBuckner CB, Harmon BH, Pallin JS. The radiology of abnormal

intrathoracic air. Current Problems in Diagnostic Radiology, 17(2): 37-71, Mar-Apr 1988.

Cyrlak D, Milne EN, Imray TJ. Pneumomediastinum: A diagnostic problem. Critical Reviews in Diagnostic Imaging, 23(1): 75-117, 1984.

Felson. Gamuts in Radiology.Holmes KD, McGuirt WF. Spontaneous Pneumomediastinum: Evaluation

and Treatment. Journal of Family Practice, 31(4): 422-9, Oct 1990.Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and Mediastinal

Emphysema. Archives of Internal Medicine, 144(7): 1447-53, July 1984.

Radiologic Clinics of North America Series.Smith BA, Ferguson DB. Disposition of spontaneous

pneumomediastinum. American Journal of Emergency Medicine, 9(3): 256-9, May 1991.