Hamman's Sign Revisited* Pneumothorax or Pneumomediastinum? Michll,.{ H. BI/Il/IuHln, M.D., FCC.P.; llncl Stt'ven A. Sllllll, M.D., EC.C.P.

Louis Hamman described distinctive chest noises and emphasized their association with pneumomediastinum in 1937. However, the etiology of Hamman's sign remains incompletely defined and its association with pneumothorax underemphasized. We present a patient with pneumothorax and Hamman's sign assessed by computed chest tomography. Tomography suggested an alternate genesis of Hamman's sign; free pleural air may be cyclically channeled through a lung fissure thus creating chest sounds. (Chest 1992; 102:1281-82)

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neumothorax rarely «1 percent) is accompanied by a noise in the chest. I Hanunan's si~n is one such chest findin~ described hy Louis Hamman in 1937.' In this and snbSl'(IUent cases, he described an infrequent chest noise and focused on its association with pneumomediastinum."" He also alluded to an association of the noise with pneumothorax." Thl' association of Hamman's si~n with both pneumomediastinum and pneumothorax and the fact that it was considered dia~nostisis of Hamman's si~n." The noise was dl'scrihed as a crllnchin~, 11lIbblin~, poppin~, eracklin~, c1ickin~ or poppin~ sound and, once heard, was an unmistakable findin~ readily reco~nized in future patients!' Hamman postulated that pneumomediastinum was not only an important etiolo~y of the chest noise but also a potential si~n of spontaneous pneumothorax. Additionally, he emphasized that these unusual chest noises were one of several key si~ns of mediastinal air.' If such a chest noisl' was observed in the presence ofa pneumothorax, Hamman su~ested that rupture of mediastinal air into the pleural space was the ~enesis of the pneumothorax. However, Hamman did not haw tIlt' technoloh'Y at his disposal to validate the proposed patho~enesis of the ··l·hest noise." We descrihe what we believe to he the first patient with a primary spontaneous pneumothorax and Hamman's si~n to have Ill'en assessed by computed chest tomo~raphy and

On examination the patient had normal vital si~ns hut appeared anxious. The skin of the patient's chest and of the head and neck was not crepitant. lie had symmetric hilateral excursions of the chest wall with normal hreath sounds and percussion tones. Cardiovascular examination was normal. However, when the patient was placed in the left lateral decuhitus position a visual pulsation of the chest wall was noted in the left anterior axillary line, lower area of the ehest. l1lincident with an audihle poppin~ sound. The use of a stetlwSl1lpe was not necessary to hear the poppin~. The intensity of the chest wall pulsations and poppin~ sound varied while in the left lateral decuhitus position and mnld at times he detected when the patient was in the supine position. These ohservations were mincident with the cardiac cycle. The patientl1mld reliahly indicate when the huhhlin~ sensation was present in the ahsence of the visual pulsations. In these instances, auscultation revealed a poppinR noise synchronous with the cardiac cycle. A chest radio~raph revealed a left pneumothorax occupyinR approximately 15 percent of the hemithorax. While the patient was in the supine position, l1lmputerized chest tomo~raphy (Fi~ I) demonstrated a left-sided pneumothorax with air ahullin~ the pericardium inferiorly alon~ the parietal pleural surface and air trackin~ up the major fissure; no mediastinal air was observed. An ecl)l)(:ardio~ram was normal. A 14- French chest tulle was plaeed with prompt resolution of the pneumothorax. huhhlin~ sensation, poppin~ noise and ehest pulsations. Respiratory and cardiac examination were normal shortly after ehesttulle placement and two weeks later. DISCUSSION

Hamman's si~n traditionally has been associated with pneumomediastinum"" and is so noted in current textbooks. 7 Others have remarked upon an association of Hamman's sign and pneumothorax, particularly left-sided pneumothorax.""" Despite these publications, Hamman's original descriptions of unusual chest noises and his emphasis on their association with mediastinal air may lead to misdiah'llosis of pneumomediastinum and an overlooked pneumothorax.·'" Hamman's initial description of this unusual chest sound was reported in 1937 and included six patients with a seventh added in a subsequent publication the same year; however, in only two of the seven patients was pneumomediastinum l~lIIfirmed by chest radiograph as well as by the presence of subcutaneous air. '"' Two of the seven patients

echocardil)~raphy.

CASE REPORT

A 26-year-old healthy mall. who was a nonsmoker. came to our emer~ency room with a one-week history of left-sided chest discomfort. The disl1l1nfort. which be~an acntdy while at rest. extended from his left parasternal area to his left scapula. The pain was intense, pleuritic and associated with mild dyspnea. He noted the ~radual onset of a "poppin~ noise" aCl~)mpanied hy visual pnlsations of the skin in the left lower area of the chest inl111ljunction with "feelin~ that he had IlIIhhles Howin~ throu~h his chest." The noise and huhhlin~ sensation were most notahle in the left lateral decuhitus positiou hut also ol'curred occasionally when he was in the snpine position. The chest dismmfort ~radually ahated over the next few days hut tilt' poppin~ and huhhlin~ l111ltinued, promptin~ the patient to seek medical evaluation. *From the Division of PulmonarY and Critical Care Medicine, Medical University of South Carolina, Charleston.

/U'I,nnt requests: Dr. BllU I/lll 1111, Pu/"umllry (lI1l/ Cnticll/ Cllrl! Medici/I

Hamman's sign revisited. Pneumothorax or pneumomediastinum?

Louis Hamman described distinctive chest noises and emphasized their association with pneumomediastinum in 1937. However, the etiology of Hamman's sig...
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