Spontaneous pneumomediastinum in children and adolescents
- Ammar A Saadoon, MBChB, FRCPCH
Ammar A Saadoon, MBChB, FRCPCH
- Section of Pediatric Pulmonary, Department of Pediatrics
- School of Medicine, University of Alabama at Birmingham
- Ibrahim A Janahi, MD
Ibrahim A Janahi, MD
- Professor of Pediatrics
- Weill-Cornell Medical College, Qatar
Spontaneous pneumomediastinum (SPM) is uncommon in children. When it occurs, it is often associated with asthma. Like spontaneous pneumothorax, SPM mainly affects adolescent males with a tall, thin body habitus [1-3].
The pathogenesis, evaluation, and treatment of isolated SPM in children will be reviewed here. SPM associated with pneumothorax has a distinct pathogenesis and its management is similar to that of the pneumothorax itself. Pneumomediastinum associated with trauma is discussed separately. (See "Spontaneous pneumothorax in children" and "Overview of intrathoracic injuries in children".)
Pneumomediastinum is defined as the presence of air or other gas in the mediastinum, and is also known as mediastinal emphysema . Pneumomediastinum can be categorized as spontaneous (SPM) or traumatic. Traumatic pneumomediastinum is caused by blunt or penetrating trauma to the chest, or iatrogenic injury, such as that produced by thoracic surgery. Mechanical ventilation is a common cause of barotrauma and pneumomediastinum. Pneumomediastinum caused by mechanical ventilation is often considered a type of traumatic pneumomediastinum, rather than spontaneous pneumomediastinum. (See "Overview of intrathoracic injuries in children".)
Some authors distinguish between primary SPM (in which there is no underlying lung disease that would predispose the individual to air leak) and secondary SPM (in which there is an underlying airway disease, such as cystic fibrosis or asthma). The patient's prognosis and management is driven by the underlying lung disease, if any, rather than by the SPM itself.
SPM is uncommon in children. The reported incidence varies widely, ranging from 1 in 800 to 1 in 42,000 adult and pediatric patients admitted to a hospital [5,6], and the rate of SPM among children presenting for emergency treatment of asthma is between 0.3 and 5 percent . The wide range of reported incidence rates is probably due to differences in the diagnostic methods used and also to the severity of symptoms in the population studied. Many more cases are detected if patients presenting with sudden chest pain or shortness of breath are routinely screened for SPM. As an example, in a study employing routine screening of young adults admitted for unexplained chest pain or dyspnea, the incidence of SPM was 1:368 . Some studies suggest that SPM is often missed among children who present to an emergency department with chest pain [1,8].
- Yellin A, Gapany-Gapanavicius M, Lieberman Y. Spontaneous pneumomediastinum: is it a rare cause of chest pain? Thorax 1983; 38:383.
- Dekel B, Paret G, Szeinberg A, et al. Spontaneous pneumomediastinum in children: clinical and natural history. Eur J Pediatr 1996; 155:695.
- Jougon JB, Ballester M, Delcambre F, et al. Assessment of spontaneous pneumomediastinum: experience with 12 patients. Ann Thorac Surg 2003; 75:1711.
- Mason, R. Pneumomediastinum and mediastinitis. In: Murray and Nadel's Textbook of Respiratory Medicine, 4th ed, Elsevier Health Sciences, 2005. Chapter 72.
- McMahon DJ. Spontaneous pneumomediastinum. Am J Surg 1976; 131:550.
- Bodey, GP. Medical mediastinal emphysema. Ann Intern Med 1961; 54:46.
- Stack AM, Caputo GL. Pneumomediastinum in childhood asthma. Pediatr Emerg Care 1996; 12:98.
- Sturtz GS. Spontaneous mediastinal emphysema. Pediatrics 1984; 74:431.
- Hauri-Hohl A, Baenziger O, Frey B. Pneumomediastinum in the neonatal and paediatric intensive care unit. Eur J Pediatr 2008; 167:415.
- Chalumeau M, Le Clainche L, Sayeg N, et al. Spontaneous pneumomediastinum in children. Pediatr Pulmonol 2001; 31:67.
- Macklin, CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications. Arch Intern Med 1939; 64:913.
- Vanzo V, Bugin S, Snijders D, et al. Pneumomediastinum and pneumopericardium in an 11-year-old rugby player: a case report. J Athl Train 2013; 48:277.
- Pourmotabed S, Jalili M. Pneumomediastinum following Crystal Use: A Report of Two Cases. Case Rep Emerg Med 2016; 2016:9730484.
- McDermott R, Tsang K, Hamilton N, Belton M. Recreational nitrous oxide inhalation as a rare cause of spontaneous pneumomediastinum. BMJ Case Rep 2015; 2015.
- Allen CJ, Teisch LF, Stahl KD. Spontaneous pneumomediastinum, pneumopericardium and epidural pneumatosis: insights on clinical management. Acute Card Care 2015; 17:20.
- Herlan DB, Landreneau RJ, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular "blow holes". Chest 1992; 102:503.
- Beg MH, Ansari MM. Traumatic tension pneumomediastinum mimicking cardiac tamponade. Thorax 1988; 43:576.
- Mohamed IS, Lee YH, Yamout SZ, et al. Ultrasound guided percutaneous relief of tension pneumomediastinum in a 1-day-old newborn. Arch Dis Child Fetal Neonatal Ed 2007; 92:F458.
- Rao KL, Imamuddin S, Kumar AP. Isolated tension pneumopericardium in a case of acute lymphoblastic leukemia. Indian Heart J 2013; 65:705.
- Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg 1984; 37:511.
- el Gamel A, Barrett P, Kopff G. Pneumopericardium: a rare cause of cardiac tamponade in an infant on a positive pressure ventilation. Acta Paediatr 1994; 83:1220.
- Wong KS, Wu HM, Lai SH, Chiu CY. Spontaneous pneumomediastinum: analysis of 87 pediatric patients. Pediatr Emerg Care 2013; 29:988.
- Lee CY, Wu CC, Lin CY. Etiologies of spontaneous pneumomediastinum in children in middle Taiwan. Pediatr Pulmonol 2010; 45:869.
- Yamada K, Shinmoto H, Hamamoto M, et al. Pneumonia induced by swine-origin influenza A (H1N1) infection: chest computed tomography findings in children. Jpn J Radiol 2011; 29:712.
- Mumford AD, Ashkan K, Elborn S. Clinically significant pulmonary barotrauma after inflation of party balloons. BMJ 1996; 313:1619.
- Grossman A, Romem A, Azaria B, et al. Pneumomediastinum in student aviators: 10 cases with return to flying duty. Aviat Space Environ Med 2005; 76:63.
- Forshaw MJ, Khan AZ, Strauss DC, et al. Vomiting-induced pneumomediastinum and subcutaneous emphysema does not always indicate Boerhaave's syndrome: report of six cases. Surg Today 2007; 37:888.
- Engum SA, Grosfeld JL, West KW, et al. Improved survival in children with esophageal perforation. Arch Surg 1996; 131:604.
- Burton EM, Riggs W Jr, Kaufman RA, Houston CS. Pneumomediastinum caused by foreign body aspiration in children. Pediatr Radiol 1989; 20:45.
- Zaia BE, Wheeler S. Pneumomediastinum after inhalation of helium gas from party balloons. J Emerg Med 2010; 38:155.
- Shackelford D, Casani JA. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction. Ann Emerg Med 1993; 22:248.
- Panacek EA, Singer AJ, Sherman BW, et al. Spontaneous pneumomediastinum: clinical and natural history. Ann Emerg Med 1992; 21:1222.
- Maeder M, Ullmer E. Pneumomediastinum and bilateral pneumothorax as a complication of cocaine smoking. Respiration 2003; 70:407.
- Zachariah S, Gharahbaghian L, Perera P, Joshi N. Spontaneous pneumomediastinum on bedside ultrasound: case report and review of the literature. West J Emerg Med 2015; 16:321.
- Huon LK, Chang YL, Wang PC, Chen PY. Head and neck manifestations of spontaneous pneumomediastinum. Otolaryngol Head Neck Surg 2012; 146:53.
- Roe PF, Kulkarni BN. Pneumomediastinum in children with cough. Br J Dis Chest 1967; 61:147.
- Sahni S, Verma S, Grullon J, et al. Spontaneous pneumomediastinum: time for consensus. N Am J Med Sci 2013; 5:460.
- Marasco SF, Lim HK. Ecstasy-associated pneumomediastinum. Ann R Coll Surg Engl 2007; 89:389.
- Pène P, Bourgeade A, Serres JJ, Lesquerre C. [Mediastinal emphysema, a frequent complication of measles in tropical environment. 46 cases]. Sem Hop 1970; 46:989.
- Hamman, L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939; 64:1.
- Zylak CM, Standen JR, Barnes GR, Zylak CJ. Pneumomediastinum revisited. Radiographics 2000; 20:1043.
- Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. AJR Am J Roentgenol 1996; 166:1041.
- Levin B. The continuous diaphragm sign. A newly-recognized sign of pneumomediastinum. Clin Radiol 1973; 24:337.
- Lawal TA, Glüer S, Reismann M, et al. Spontaneous neonatal pneumomediastinum: the "spinnaker sail" sign. Eur J Pediatr Surg 2009; 19:50.
- NACLERIO EA. The V sign in the diagnosis of spontaneous rupture of the esophagus (an early roentgen clue). Am J Surg 1957; 93:291.
- Hammond DI. The "ring-around-the-artery" sign in pneumomediastinum. J Can Assoc Radiol 1984; 35:88.
- Agarwal PP. The ring-around-the-artery sign. Radiology 2006; 241:943.
- Megremis S, Stefanaki S, Tsekoura T, Tsilimigaki A. Spontaneous pneumomediastinum in a child: sonographic detection in a case with minimal findings on chest radiography. J Ultrasound Med 2008; 27:303.
- Ng L, Saul T, Lewiss RE. Sonographic evidence of spontaneous pneumomediastinum. Am J Emerg Med 2013; 31:462.e3.
- Caceres M, Ali SZ, Braud R, et al. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008; 86:962.
- Abolnik I, Lossos IS, Breuer R. Spontaneous pneumomediastinum. A report of 25 cases. Chest 1991; 100:93.
- LITTMANN D. Electrocardiographic phenomena associated with spontaneous pneumothorax and mediastinal emphysema. Am J Med Sci 1946; 212:682.
- Uva JL. Spontaneous pneumothoraces, pneumomediastinum, and pneumoperitoneum: consequences of smoking crack cocaine. Pediatr Emerg Care 1997; 13:24.
- Brearley WD Jr, Taylor L 3rd, Haley MW, Littmann L. Pneumomediastinum mimicking acute ST-segment elevation myocardial infarction. Int J Cardiol 2007; 117:e73.
- Takada K, Matsumoto S, Hiramatsu T, et al. Management of spontaneous pneumomediastinum based on clinical experience of 25 cases. Respir Med 2008; 102:1329.
- Macia I, Moya J, Ramos R, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg 2007; 31:1110.
- Fitzwater JW, Silva NN, Knight CG, et al. Management of spontaneous pneumomediastinum in children. J Pediatr Surg 2015; 50:983.
- Markarian MK, MacIntyre DA, Cousins BJ, et al. Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection. Am J Emerg Med 2008; 26:515.e1.
- Patel A, Kesler B, Wise RA. Persistent pneumomediastinum in interstitial fibrosis associated with rheumatoid arthritis: treatment with high-concentration oxygen. Chest 2000; 117:1809.
- Ploysongsang Y, Wiltse DW. Effects of breathing pattern and oxygen upon the alveolar arterial oxygen pressure difference in lung disease. Respiration 1985; 47:39.
- Gerazounis M, Athanassiadi K, Kalantzi N, Moustardas M. Spontaneous pneumomediastinum: a rare benign entity. J Thorac Cardiovasc Surg 2003; 126:774.
- Swar MO, Srikrishna BV, Abusin A, Khogali FM. Post-measles pneumomediastinum and subcutaneous emphysema in malnourished children. Afr J Med Med Sci 2002; 31:259.
- Predisposing conditions or triggers
- CLINICAL PRESENTATION
- Physical examination
- - Chest radiograph
- - Ultrasonography
- Further evaluation for associated problems
- DIFFERENTIAL DIAGNOSIS
- Esophageal perforation
- SUMMARY AND RECOMMENDATIONS