BMJ 2014;348:g1661 doi: 10.1136/bmj.g1661 (Published 25 February 2014)
Page 1 of 3
Endgames
ENDGAMES PICTURE QUIZ
Chest pain and neck discomfort in a young man 1
2
Dermot Linden core medical trainee , David Courtney general practitioner trainee , Muralis 3 3 Shyamsundar specialty registrar , Richard Hewitt consultant Department of Intensive Care, Ulster Hospital, Belfast BT16 1RH, UK; 2Department of Medicine, Ulster Hospital, Belfast, UK; 3Department of Respiratory Medicine, Ulster Hospital, Belfast, UK 1
A 21 year old man presented to his general practitioner with intermittent left sided pain in the anterior chest wall associated with neck discomfort. The pain was reported as “stabbing” in nature and had arisen suddenly while watching television. He had no history of trauma before the onset of symptoms, and the pain was not exacerbated by inspiration or effort. His medical history and physical examination were unremarkable. His GP referred him for outpatient cardiology assessment and prescribed simple analgesia.
Several days later he attended the local emergency department with worsening chest pain and dyspnoea. On examination, chest expansion was equal and breath sounds were normal, although there was crepitus on auscultation of the precordium. Palpation of the neck and supraclavicular fossae detected subcutaneous emphysema. His respiratory rate was 25 breaths/min and his oxygen saturations were 100%. A chest radiograph (fig 1) was abnormal and he was admitted for computed tomography of the chest. No abnormalities were seen on a water soluble oral contrast swallow. His full blood count and inflammatory markers were within normal limits.
Fig 1 The patient’s chest radiograph on admission
Questions 1 What abnormality is shown on the chest radiograph? 2 What is the most likely diagnosis? 3 What are the differential diagnoses? 4 What does crepitus on auscultation of the precordium indicate? 5 How should this patient be managed?
Correspondence to: D Linden [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1661 doi: 10.1136/bmj.g1661 (Published 25 February 2014)
Page 2 of 3
ENDGAMES
Answers
1 What abnormality is shown on the chest radiograph? Short answer The chest radiograph shows paratracheal free air.
Long answer
This is an anterioposterior chest radiograph. Linear lucencies can be seen in the suprasternal region and superior mediastinum projected parallel to the trachea (fig 2). Changes are most prominent to the left of the trachea. The appearances are in keeping with gas in the soft tissues at the base of the neck extending into the superior mediastinum. Spontaneous pneumomediastinum may lead to several interesting chest radiograph signs including subcutaneous emphysema, pneumopericardium, the “ring around the artery sign,” and the “continuous diaphragm sign.”
2 What is the most likely diagnosis? Short answer
The diagnosis is spontaneous pneumomediastinum (Hamman’s syndrome).
Long answer
The diagnosis is spontaneous pneumomediastinum (Hamman’s syndrome), which is the presence of free air within the mediastinum in the absence of demonstrable pulmonary disease. This is a benign condition that is more common in adolescent males and can occur without precipitating factor(s), although it can be associated with asthma, coughing, and emesis.1 Spontaneous pneumomediastinum may also arise during the inhalation of illicit substances such as cocaine and marijuana, and as a result of barotrauma when performing Valsalva manoeuvres.2 3 Although the clinical presentation is extremely variable, the most common presenting symptoms are chest pain, dyspnoea, and surgical emphysema.4 Spontaneous pneumomediastinum is a rare condition and most descriptions in the literature are in the form of case reports. The estimated incidence varies from 1 in 800 to 1 in 30 000 presentations at the emergency department, but its true incidence is probably underestimated.1 5
3 What are the differential diagnoses? Short answer
The differential diagnosis should include mediastinitis, tissue dissection after pneumothorax, chest wall trauma, and oesophageal perforation (Boerhaave’s syndrome).
Long answer
Fig 2 Chest radiograph on admission showing free air (arrow)
Figure 3 is a contrast enhanced axial image at the level of the superior mediastinum where the left brachiocephalic vein passes anterior to the root of the right common carotid artery. It shows areas of decreased attenuation lying posterior to the sternum, adjacent to the left brachiocephalic vein and to the right of the trachea. The attenuation values of these areas are in keeping with gas. No parenchymal lung disease is seen. The pattern is consistent with the diagnosis of a pneumomediastinum.
The presence of pneumomediastinum on a chest radiograph is often a cause of great concern and it is important to exclude an underlying intrathoracic or extrathoracic disease process. Intrathoracic causes of pneumomediastinum include alveolar rupture after a sudden rise in intrathoracic pressure owing to vigorous coughing, sneezing, or air travel. Intrathoracic infection affecting the mediastinum (mediastinitis) may lead to pneumomediastinum. Oesophageal perforation (Boerhaave’s syndrome) must also be considered, so it is vital to ask about vomiting and retching during the history taking. Extrathoracic causes of pneumomediastinum include dental drilling, tooth extraction, facial bone fracture, and endotracheal intubation. Perforation of abdominal viscus and pneumoperitoneum may also give rise to pneumomediastinum.
4 What does crepitus on auscultation of the precordium indicate? Short answer
The presence of crepitus synchronised with the heart sounds on auscultation of the precordium is known as Hamman’s sign.
Long answer
Fig 3 Section of the chest computed tomogram showing aberrant free air within the mediastinum (arrow) For personal use only: See rights and reprints http://www.bmj.com/permissions
Spontaneous pneumomediastinum was initially described by Louis Hamman in 1939, so the presence of a “crunching” or “crackling” sound occurring in synchrony with the heart sounds is referred to as Hamman’s sign.1 Hamman’s sign is not always found in patients with spontaneous pneumomediastinum, being present in 5-85%.6 7 Hammans’ sign may also be present in left sided pneumothorax, lingular bulla, and oesophageal distension. The most common clinical features of spontaneous pneumomediastinum are chest pain, dyspnoea, and subcutaneous Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1661 doi: 10.1136/bmj.g1661 (Published 25 February 2014)
Page 3 of 3
ENDGAMES
emphysema.8 Case reports also describe atypical symptoms such as sore throat, hoarseness, dysphonia, dysphagia, and neck pain.9-11
5 How should this patient be managed? Short answer
Spontaneous pneumomediastinum is a benign condition that can be managed conservatively with oxygen therapy, analgesia, and rest.
Long answer
Spontaneous pneumomediastinum is a benign condition and adverse outcomes are rare.1 4 6 Patients should be admitted to hospital and observed for 24 hours. Initially it is important to prescribe appropriate analgesia. Although patients are advised to rest so that manoeuvres that increase intrathoracic pressure are avoided, such measures are not evidence based. High concentration oxygen therapy may be considered in patients with severe dyspnoea to hasten air absorption.12 13 Further radiological surveillance is needed to confirm resolution of pneumomediastinum. In rare circumstances patients may develop tension pneumomediastinum. The management options for tension pneumomediastinum include insertion of a percutaneous mediastinal drainage tube and limited mediastinotomy.14
swallow. As a result he was managed conservatively. At outpatient clinic review four weeks’ later, his chest radiograph was unremarkable and he was discharged without further complications. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent obtained. 1 2 3 4 5 6 7 8 9 10
Newcomb AE, Clarke PC. Spontaneous pneumomediastinum a benign curiosity or a significant problem? Chest 2005;128:3298-302. Johnson M, Smith R, Morrison D, Laszlo G, White RJ. Large lung bullae in marijuana smokers. Thorax 2000;55:340-2. Janes SM, Ind PW, Jackson J. Images in thorax. Crack inhalation induced pneumomediastinum. Thorax 2004;59:360. Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE Jr. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008;86:962-6. McMahon DJ. Spontaneous pneumomediastinum. Am J Surg 1976;131:550-1. Yellin A, Gapany-Gapanavicius M, Lieberman Y. Spontaneous pneumomediastinum: is it a rare cause of chest pain? Thorax 1983;38:383. Campillo-Soto A, Coll-Salinas A, Soria-Aledo V, Blanco-Barrio A, Flores-Pastor B, Candel-Arenas M, et al. Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases. Arch Bronconeumol 2005;41528-31. Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg 2007;31:1110-4. Werne C, Ulreich S. An unusual presentation of spontaneous pneumomediastinum. Ann Emerg Med 1985;14:1010-3. Anthony C, Edwards. Atypical presentation of spontaneous pneumomediastinum. Ann Thorac Surg 1994;58:1758-60. Baskaran RK. Image on spontaneous pneumomediastinum presenting as sore throat. Emerg Med J 2010;27:241. Patel A, Kesler B, Wise RA. Persistent pneumomediastinum in interstitial fibrosis associated with rheumatoid arthritis: treatment with high-concentration oxygen. Chest 2000;117:1809. Munsell WP. Pneumomediastinum. A report of 28 cases and review of the literature. JAMA 1967;202:689. Herlan DB, Landreneau RJ, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular “blow holes.” Chest 1992;102:503. Blencowe NS, Strong S, Hollowood AD. Easily missed? Spontaneous oesophageal rupture. BMJ 2013;346:38-9.
Pneumomediastinum is a worrying finding on chest radiography and computed tomography must be performed to exclude underlying disease. Patients who also have vomiting or retching require urgent contrast swallow to exclude rupture of the aerodigestive tract (Boerhaave’s syndrome). All patients with Boerhaave’s syndrome should be resuscitated appropriately and referred for urgent oesophagogastric specialist opinion.15
11
Patient outcome
Cite this as: BMJ 2014;348:g1661
The patient was initially treated with oxygen therapy and simple analgesia. No abnormalities were seen on water soluble contrast
For personal use only: See rights and reprints http://www.bmj.com/permissions
12 13 14 15
© BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Endgames
ENDGAMES PICTURE QUIZ
Chest pain and neck discomfort in a young man 1
2
Dermot Linden core medical trainee , David Courtney general practitioner trainee , Muralis 3 3 Shyamsundar specialty registrar , Richard Hewitt consultant Department of Intensive Care, Ulster Hospital, Belfast BT16 1RH, UK; 2Department of Medicine, Ulster Hospital, Belfast, UK; 3Department of Respiratory Medicine, Ulster Hospital, Belfast, UK 1
A 21 year old man presented to his general practitioner with intermittent left sided pain in the anterior chest wall associated with neck discomfort. The pain was reported as “stabbing” in nature and had arisen suddenly while watching television. He had no history of trauma before the onset of symptoms, and the pain was not exacerbated by inspiration or effort. His medical history and physical examination were unremarkable. His GP referred him for outpatient cardiology assessment and prescribed simple analgesia.
Several days later he attended the local emergency department with worsening chest pain and dyspnoea. On examination, chest expansion was equal and breath sounds were normal, although there was crepitus on auscultation of the precordium. Palpation of the neck and supraclavicular fossae detected subcutaneous emphysema. His respiratory rate was 25 breaths/min and his oxygen saturations were 100%. A chest radiograph (fig 1) was abnormal and he was admitted for computed tomography of the chest. No abnormalities were seen on a water soluble oral contrast swallow. His full blood count and inflammatory markers were within normal limits.
Fig 1 The patient’s chest radiograph on admission
Questions 1 What abnormality is shown on the chest radiograph? 2 What is the most likely diagnosis? 3 What are the differential diagnoses? 4 What does crepitus on auscultation of the precordium indicate? 5 How should this patient be managed?
Correspondence to: D Linden [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1661 doi: 10.1136/bmj.g1661 (Published 25 February 2014)
Page 2 of 3
ENDGAMES
Answers
1 What abnormality is shown on the chest radiograph? Short answer The chest radiograph shows paratracheal free air.
Long answer
This is an anterioposterior chest radiograph. Linear lucencies can be seen in the suprasternal region and superior mediastinum projected parallel to the trachea (fig 2). Changes are most prominent to the left of the trachea. The appearances are in keeping with gas in the soft tissues at the base of the neck extending into the superior mediastinum. Spontaneous pneumomediastinum may lead to several interesting chest radiograph signs including subcutaneous emphysema, pneumopericardium, the “ring around the artery sign,” and the “continuous diaphragm sign.”
2 What is the most likely diagnosis? Short answer
The diagnosis is spontaneous pneumomediastinum (Hamman’s syndrome).
Long answer
The diagnosis is spontaneous pneumomediastinum (Hamman’s syndrome), which is the presence of free air within the mediastinum in the absence of demonstrable pulmonary disease. This is a benign condition that is more common in adolescent males and can occur without precipitating factor(s), although it can be associated with asthma, coughing, and emesis.1 Spontaneous pneumomediastinum may also arise during the inhalation of illicit substances such as cocaine and marijuana, and as a result of barotrauma when performing Valsalva manoeuvres.2 3 Although the clinical presentation is extremely variable, the most common presenting symptoms are chest pain, dyspnoea, and surgical emphysema.4 Spontaneous pneumomediastinum is a rare condition and most descriptions in the literature are in the form of case reports. The estimated incidence varies from 1 in 800 to 1 in 30 000 presentations at the emergency department, but its true incidence is probably underestimated.1 5
3 What are the differential diagnoses? Short answer
The differential diagnosis should include mediastinitis, tissue dissection after pneumothorax, chest wall trauma, and oesophageal perforation (Boerhaave’s syndrome).
Long answer
Fig 2 Chest radiograph on admission showing free air (arrow)
Figure 3 is a contrast enhanced axial image at the level of the superior mediastinum where the left brachiocephalic vein passes anterior to the root of the right common carotid artery. It shows areas of decreased attenuation lying posterior to the sternum, adjacent to the left brachiocephalic vein and to the right of the trachea. The attenuation values of these areas are in keeping with gas. No parenchymal lung disease is seen. The pattern is consistent with the diagnosis of a pneumomediastinum.
The presence of pneumomediastinum on a chest radiograph is often a cause of great concern and it is important to exclude an underlying intrathoracic or extrathoracic disease process. Intrathoracic causes of pneumomediastinum include alveolar rupture after a sudden rise in intrathoracic pressure owing to vigorous coughing, sneezing, or air travel. Intrathoracic infection affecting the mediastinum (mediastinitis) may lead to pneumomediastinum. Oesophageal perforation (Boerhaave’s syndrome) must also be considered, so it is vital to ask about vomiting and retching during the history taking. Extrathoracic causes of pneumomediastinum include dental drilling, tooth extraction, facial bone fracture, and endotracheal intubation. Perforation of abdominal viscus and pneumoperitoneum may also give rise to pneumomediastinum.
4 What does crepitus on auscultation of the precordium indicate? Short answer
The presence of crepitus synchronised with the heart sounds on auscultation of the precordium is known as Hamman’s sign.
Long answer
Fig 3 Section of the chest computed tomogram showing aberrant free air within the mediastinum (arrow) For personal use only: See rights and reprints http://www.bmj.com/permissions
Spontaneous pneumomediastinum was initially described by Louis Hamman in 1939, so the presence of a “crunching” or “crackling” sound occurring in synchrony with the heart sounds is referred to as Hamman’s sign.1 Hamman’s sign is not always found in patients with spontaneous pneumomediastinum, being present in 5-85%.6 7 Hammans’ sign may also be present in left sided pneumothorax, lingular bulla, and oesophageal distension. The most common clinical features of spontaneous pneumomediastinum are chest pain, dyspnoea, and subcutaneous Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1661 doi: 10.1136/bmj.g1661 (Published 25 February 2014)
Page 3 of 3
ENDGAMES
emphysema.8 Case reports also describe atypical symptoms such as sore throat, hoarseness, dysphonia, dysphagia, and neck pain.9-11
5 How should this patient be managed? Short answer
Spontaneous pneumomediastinum is a benign condition that can be managed conservatively with oxygen therapy, analgesia, and rest.
Long answer
Spontaneous pneumomediastinum is a benign condition and adverse outcomes are rare.1 4 6 Patients should be admitted to hospital and observed for 24 hours. Initially it is important to prescribe appropriate analgesia. Although patients are advised to rest so that manoeuvres that increase intrathoracic pressure are avoided, such measures are not evidence based. High concentration oxygen therapy may be considered in patients with severe dyspnoea to hasten air absorption.12 13 Further radiological surveillance is needed to confirm resolution of pneumomediastinum. In rare circumstances patients may develop tension pneumomediastinum. The management options for tension pneumomediastinum include insertion of a percutaneous mediastinal drainage tube and limited mediastinotomy.14
swallow. As a result he was managed conservatively. At outpatient clinic review four weeks’ later, his chest radiograph was unremarkable and he was discharged without further complications. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent obtained. 1 2 3 4 5 6 7 8 9 10
Newcomb AE, Clarke PC. Spontaneous pneumomediastinum a benign curiosity or a significant problem? Chest 2005;128:3298-302. Johnson M, Smith R, Morrison D, Laszlo G, White RJ. Large lung bullae in marijuana smokers. Thorax 2000;55:340-2. Janes SM, Ind PW, Jackson J. Images in thorax. Crack inhalation induced pneumomediastinum. Thorax 2004;59:360. Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE Jr. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008;86:962-6. McMahon DJ. Spontaneous pneumomediastinum. Am J Surg 1976;131:550-1. Yellin A, Gapany-Gapanavicius M, Lieberman Y. Spontaneous pneumomediastinum: is it a rare cause of chest pain? Thorax 1983;38:383. Campillo-Soto A, Coll-Salinas A, Soria-Aledo V, Blanco-Barrio A, Flores-Pastor B, Candel-Arenas M, et al. Spontaneous pneumomediastinum: descriptive study of our experience with 36 cases. Arch Bronconeumol 2005;41528-31. Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg 2007;31:1110-4. Werne C, Ulreich S. An unusual presentation of spontaneous pneumomediastinum. Ann Emerg Med 1985;14:1010-3. Anthony C, Edwards. Atypical presentation of spontaneous pneumomediastinum. Ann Thorac Surg 1994;58:1758-60. Baskaran RK. Image on spontaneous pneumomediastinum presenting as sore throat. Emerg Med J 2010;27:241. Patel A, Kesler B, Wise RA. Persistent pneumomediastinum in interstitial fibrosis associated with rheumatoid arthritis: treatment with high-concentration oxygen. Chest 2000;117:1809. Munsell WP. Pneumomediastinum. A report of 28 cases and review of the literature. JAMA 1967;202:689. Herlan DB, Landreneau RJ, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular “blow holes.” Chest 1992;102:503. Blencowe NS, Strong S, Hollowood AD. Easily missed? Spontaneous oesophageal rupture. BMJ 2013;346:38-9.
Pneumomediastinum is a worrying finding on chest radiography and computed tomography must be performed to exclude underlying disease. Patients who also have vomiting or retching require urgent contrast swallow to exclude rupture of the aerodigestive tract (Boerhaave’s syndrome). All patients with Boerhaave’s syndrome should be resuscitated appropriately and referred for urgent oesophagogastric specialist opinion.15
11
Patient outcome
Cite this as: BMJ 2014;348:g1661
The patient was initially treated with oxygen therapy and simple analgesia. No abnormalities were seen on water soluble contrast
For personal use only: See rights and reprints http://www.bmj.com/permissions
12 13 14 15
© BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
