Spontaneous Pneumomediastinum CDR D. J. McMahon, MC USN, Beaufort, South Carolina

Air in the mediastinum is a dramatic finding that can be associated with a catastrophic event, such as esophageal perforation. There is, however, a benign, self-limited condition known as spontaneous mediastinum. Our experience with five cases of this syndrome is presented. Material and Methods During the period from September 1,1974 through August 31, 1975, five patients were admitted to our hospital with a diagnosis of spontaneous pneumomediastinum. All were men with an average age of 18 years (range, 17 to 19 years). All five patients presented with a chief complaint of anterior chest pain. Past medical history was negative in all patients. None of the patients related a history of trauma. Three patients were cigarette smokers. The most consistent physical finding in this group was cervical subcutaneous emphysema, demonstrated in four patients. Three patients demonstrated a mediastinal crunch on auscultation, usually best heard over the apex and along the left sternal border (Hamman’s sign). Complete blood count and urinalysis were normal in all patients. Chest x-ray films revealed mediastinal air in all patients; this is typically seen as a narrow column of air just to the left of the cardiac shadow. (Figure 1.) In four of our patients there was also radiologic evidence of air in the soft tissues of the neck. One patient also exhibited a minimal left apical pneumothorax. Patients were treated with bed rest and close observation with serial chest x-ray films. Each patient recovered completely; there were no complications. Typically, the patient becomes asymptomatic after a few days. Serial chest x-ray films reveal gradual resolution of the mediastinal air.

postulated that an alveolus ruptures and air then travels along connective tissue planes to the mediastinum. In 1967, Munsell [2] reviewed the literature, which contained 320 cases, and reported 28 new cases. He suggested transient respiratory obstruction as the etiologic factor; 40 per cent of his patients had an episode of cough emesis immediately preceding their pneumomediastinum and 14 per cent had a history of bronchial asthma. The incidence of this condition in our hospital-l case per 800 admissions-is much higher than has been reported elsewhere; Bodey [3] reported 1 case per 42,000 admissions and Munsell 1 per 7,115 admissions. This is probably explained by the fact that all our patients were Marine recruits. Marine recruit

Comments Nearly four decades ago, Hamman [I] reported seven cases of spontaneous pneumomediastinum. He From the Surgical Service, Naval Hospital, Beaufort, South Carolina. The views opinions and expressed herein are those of the author and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. Reprint requests should be addressed to CDR David J. McMahon, MC, USN. Department of Surgery, Naval Hospital, Beaufort, South Carolina 29902.

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Figure I. Chest x-ray film demonstrating pneumomediastinum.

The American Journal of Surgery

Spontaneous

training includes frequent marching and a vigorous exercise program; the recruits are encouraged to yell and sing while marching and exercising. It is possible that these activities generate high intrapulmonary pressures that may result in alveolar rupture. We saw two additional patients during the period of this study with pneumomediastinum. One had bronchial asthma and the other had pneumonia. These patients were not included in the study because I believed these underlying disease states might have contributed to the pneumomediastinum and therefore they do not represent truly spontaneous cases. It is our conclusion that spontaneous pneumomediastinum is an innocuous condition. Underlying

volume 131, May 1876

Pneumomediastinum

and associated disease must be ruled out by careful clinical evaluation; once this has been accomplished, no specific treatment is necessary. Summary Five cases of spontaneous pneumomediastinum are presented. This is a benign condition that requires no specific therapy. References 1. Hamman L: Spontaneous mediastinal emphysema. Bull Johns Hopkins Hasp64: 1, 1939 2. Munsell WP: Pneumomediastinum. JAMA 202: 129, 1967. 3. Bodey Gp: Medical mediastinal emphysema. Ann lntem W54: 46. 1961.

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Spontaneous pneumomediastinum.

Five cases of spontaneous pneumomediastinum are presented. This is a benign condition that requires no specific therapy...
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