Spontaneous Pneumomediastinum* A Report of 25 Cases Igor Abolnik, M.D.; Isidore S. Lassos, M.D.; and Raphael Breuer; M.D., F.G.G.R Spontaneous pneumomediastinum (SPM) is a relatively uncommon, infrequently reported entity. To determine the clinical presentation and sequelae of SPM, data were obtained from 25 patients: 14 from Hadassah University Hospital, and 11 from other medical institutions. The mean age was 18.8±5.2 years (±SD), with a range of 8 to 31 years. The most common presenting complaint was retrosternal pain in 22 patients (88 percent), dyspnea in 15 (60 percent), dysphagia in 10 (40 percent), and weakness in 10 (40 percent). Predisposing factors for the development of SPM could be identified in 18 patients (72 percent). Information on the sequelae of SPM during a mean period of

pneumomediastinum is uncommon, SPontaneous usually benign, and self-limited. It affects young men and usually presents with retrosternal chest pain, although other manifestations may occur.'> Previous series of cases ofSPM focused on clinical presentations and possible precipitating factors, without long-term follow-up. 1,3-6 The purpose of the present study was to determine the incidence, modes of presentation, presence of precipitating factors, and sequelae over a long-term period in a large group of patients with SPM. MATERIALS AND METHODS

To determine the incidence of hospital admissions with SPM, we performed a computerized retrospective study of discharge diagnoses in 460,544 patients hospitalized at Hadassah University Hospital in Jerusalem between June 1, 1978 and May 31, 1989. Fourteen patients with SPM were identified. Clinical data on SPM were obtained from 25 patients: 14 admitted to Hadassah University Hospital; and 11 patients admitted to other medical institutions, but followed in Hadassahs outpatient clinic. Data concerning the presenting complaints, clinical findings on admission, precipitating factors, diagnostic investigation, and inhospital outcome were gathered from medical records. Information concerning recurrence and long-term sequelae was obtained by personal interview of 23 patients and their family physicians. Two patients were lost to follow-up. RESULTS

The incidence of SPM at Hadassah University Hospital was 1:32,896 hospital admissions. In young patients (5 to 34 years), the incidence was 1:24,945. The mean age of the 25 patients with SPM was 18.8 ± 5.2 years (± SD), with a range of 8 to 31 years. There were 21 male and 4 female patients. Body build and smoking habits were not Significantly different ·From the Pulmonary Unit, Hadassah University Hospital, Hebrew University, Jerusalem, Israel. Manuscript received July 23; revision accepted November 30.

87.4±38.0 months following the initial SPM episode was obtained from 23 patients. Recurrent SPM occurred in 1 patient at 18 months, and another patient experienced 4 episodes of recurrent spontaneous pneumothorax. No other long-term sequelae were reported. We conclude that SPM is a benign self-limited disease with diverse clinical manifestations. Although uncommon, recurrences of SPM may be observed. (Chest 1991; 100:93-5)

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SPM = spontaneous pneumomediastinum

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from the general population (data not shown). The patients' complaints on admission are summarized in the following tabulation, showing numbers of patients (numbers within parentheses are percentages): Complaints Chest pain Dyspnea Neck pain WeakDess Dysphagia Backpain

Shoulder pain Swollen neck Abdominal pain Physical findings Subcutaneous emphysema

Face

Shoulders Whole body Axillae Chest Neck Hamman's sign Pulsus paradoxus Decreased heart sounds None

Retrosternal pain was the most common complaint (88 percent; 22125). The intensity of pain varied with respiration in 96 percent (24) of the patients. Dyspnea occurred in 60 percent (15), dysphagia in 40 percent (10), and weakness in 40 percent (10) of the patients. Among relevant physical findings, subcutaneous emphysema was the most common finding (60 percent; 15/25), extending to the whole body in one patient. In two nonasthmatic patients, pulsus paradoxus was found. The presence of SPM was confirmed roentgenographically in all patients. In three, concurrent pneumothorax was seen. Six patients underwent esophageal studies with contrast material, none of which demonstrated pathologic findings. Computerized tomography of the thorax, performed in one patient, revealed CHEST I 100 I 1 I JUL'(, 1991

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multiple small lung bullae. Electrocardiographic studies were performed in 14 patients. In three patients, electrocardiographic changes were observed: mild ST elevation in two; and T-wave inversion in one. Predisposing factors for the development of SPM could be identified in 18 patients (72 percent). These include physical exertion (swimming, tennis playing, and weight lifting) in six patients (24 percent), acute bronchial asthma in six (24 percent), and upperrespiratory-tract infection in three (12 percent). Bronchospasm secondary to bromine exposure, an acute attack of nonspecific cough, and prolonged screaming culminating in an attack of coughing occurred in single patients. The mean length of hospitalization was 6.3±3.9 days. Six patients with acute asthmatic attacks and one patient with bronchospasm due to bromine inhalation were treated with bronchodilators. An intercostal drain was inserted in one patient with concurrent pneumothorax. The remaining patients with SPM responded well to bed rest, with complete reabsorption of the mediastinal air. Information on recurrence and sequelae of SPM over a mean period of87.4 ± 38.0 months was obtained from 23 patients. One recurrence of SPM occurred in a 22-year-old man at 18 months. While the first episode ofSPM followed weight lifting, no predisposing factors preceded the recurrence. In another patient, four episodes of recurrent spontaneous pneumothorax occurred. No other long-term sequelae were reported by patients or their family physicians. We examined the hypothesis that the recurrence of SPM is an independent observation of a Poisson distribution." This was rejected by p

Spontaneous pneumomediastinum. A report of 25 cases.

Spontaneous pneumomediastinum (SPM) is a relatively uncommon, infrequently reported entity. To determine the clinical presentation and sequelae of SPM...
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