Ann 0101 Rhinal Laryngo199:1990
IMAGING CASE STUDY OF THE MONTH
SPONTANEOUS PNEUMOPERICARDIUM AND PNEUMOMEDIASTINUM NODAR BARTAL, MD SULEIMAN ZAARURA, MD
HAROLD MARVAN, MD TIBERIAS, ISRAEL
A lO-year-old boy was brought to the emergency room in respiratory distress. He was in good health until he awoke in the night because of severe cough. He suddenly felt a pain in the chest and experienced difficulty in breathing. On examination the patient was slightly cyanotic and dyspneic, with "ballooning" of the soft tissue of the neck. Palpation revealed subcutaneous emphysema of the neck and upper chest. Additionally there was severe bulging of the posterior pharyngeal wall and bilateral pulmonary wheezing. The radiographic findings are shown in the Figure.
period was uneventful. The boy was discharged in good health 12 days following hospitalization. Control radiographs were within normal limits. DISCUSSION
Spontaneous pneumopericardium and pneumomediastinum, sometimes called pericardial or mediastinal emphysema, is a very rare condition with a multitude of possible causes: athletics, parturition, pulmonary barotrauma, severe cough, asthma, cocaine inhalation, chlorine gas exposure, and emesis.':" Alveolar rupture as a result of a sudden increase of intrapulmonary pressure is the port of entry of the air into the mediastinum. The exact mechanism by which the air reaches the mediastinal and pericardial spaces was an enigma for a long time. Today it is commonly accepted that the air dissects along the perivascular spaces to enter the
After the diagnosis of spontaneous pericardial and mediastinal emphysema the boy was prescribed bed rest in a semisitting position. Intravenous cefazolin sodium 3.0 g per day was started. A lOO-mg daily dose of intramuscular hydrocortisone sodium succinate was given for 2 days. The hospitalization
•
Radiographs. A) Demonstrating gentle line of air, corresponding heart borders, and vascular vessels. Pericardia! thickening is seen in right lower border of heart (arrowheads). B) Demonstrating presternal subcutaneous emphysema and free air in fascial spaces of neck (arrowhead). From the ENT Unit (Bartal, Zaarura) and the X-ray Department (Marvan), Poriya Government Hospital, Tiberias, Israel. REPRINTS - Nodar Bartal, MD, ENT Unit, Poriya Government Hospital, Tiberias, 15208, Israel.
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Bartal et al, Imaging Case Study of the Month
mediastinum. From here it can decompress into the subcutaneous tissues, the deep cervical spaces, and eventually the pericardial space. I Other causes of the disease are direct trauma of the upper digestive tract, neoplasm disrupting the mucosal integrity of the esophagus, gas-producing infection, and even achalasia." The acute onset of retrosternal pain radiating to the back, neck, or shoulders is a usual clinical manifestation of the mediastinal phase of the disease. Mediastinal crepitation (Hamman's sign) is the classic physical finding at this stage. It may be accompanied by cardiac dullness on auscultation." When the air reaches the deep cervical spaces, pressure on the upper airway can create respiratory distress, as was the case with our patient.
If the process continues and dissecting air enters the pericardial space, cardiovascular dynamics may be compromised. Fatal tension pneumopericardium
with air cardiac tamponade has been reported.' The symptoms of mediastinal emphysema alone may mimic those of pericardial emphysema. Therefore, radiographic evidence of air in the pericardial space is the pathognomonic sign that must be present to establish conclusively the diagnosis of pneumopericardium." There are no pathognomonic electrocardiographic findings for pericardial emphysema, and the appearance of the echocardiogram can mimic that of pericardial effusion. 6 Spontaneous mediastinal and pericardial emphysema is almost always a self-limited condition. Treatment, which accompanies a diligent search for possible etiologic factors, consists of supportive measures: oxygen, analgesics, sedation, and careful monitoring. Most patients will recover within 1 to 2 weeks, as ours did.
REFERENCES 1. Aroesty J, Stenley RB Jr. Pneumomediastinum and cervical emphysema from the inhalation of "free base" cocaine. Otolaryngol Head Neck Surg 1986;94:372-4.
2. Harley H. Spontaneous cervical and mediastinal emphysema in asthma. Arch Otolaryngol Head Neck Surg 1987;113:11112. 3. Gapanavicius MG, Yellin A. Pneumomediastinum a complication of chlorine exposure from mixing household cleaning
agents. JAMA 1982;248:349-50. 4. Breatnach E, Han SY. Pneumopericardium occurring as a complication of achalasia. Chest 1986;90:292-3. 5. Gossage AAR, Robertson PW. Spontaneous pneumopericardium. Thorax 1976;31:460-5. 6. Luby BJ, Gerogiev M. Postpartum pneumopericardium. Obstet Gynecol 1983;62(suppl 3):465-505.
SPASTIC DYSPHONIA CONFERENCE The Voice Foundation will sponsor a state-of-the-art conference on Spastic Dysphonia, to be held July 20, 1991, at the Warwick Hotel in Philadelphia, Pennsylvania. For further information, contact The Voice Foundation, 1721 Pine Street, Philadelphia, PA 19103; (215) 735-7999.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 7, 2015
IMAGING CASE STUDY OF THE MONTH
SPONTANEOUS PNEUMOPERICARDIUM AND PNEUMOMEDIASTINUM NODAR BARTAL, MD SULEIMAN ZAARURA, MD
HAROLD MARVAN, MD TIBERIAS, ISRAEL
A lO-year-old boy was brought to the emergency room in respiratory distress. He was in good health until he awoke in the night because of severe cough. He suddenly felt a pain in the chest and experienced difficulty in breathing. On examination the patient was slightly cyanotic and dyspneic, with "ballooning" of the soft tissue of the neck. Palpation revealed subcutaneous emphysema of the neck and upper chest. Additionally there was severe bulging of the posterior pharyngeal wall and bilateral pulmonary wheezing. The radiographic findings are shown in the Figure.
period was uneventful. The boy was discharged in good health 12 days following hospitalization. Control radiographs were within normal limits. DISCUSSION
Spontaneous pneumopericardium and pneumomediastinum, sometimes called pericardial or mediastinal emphysema, is a very rare condition with a multitude of possible causes: athletics, parturition, pulmonary barotrauma, severe cough, asthma, cocaine inhalation, chlorine gas exposure, and emesis.':" Alveolar rupture as a result of a sudden increase of intrapulmonary pressure is the port of entry of the air into the mediastinum. The exact mechanism by which the air reaches the mediastinal and pericardial spaces was an enigma for a long time. Today it is commonly accepted that the air dissects along the perivascular spaces to enter the
After the diagnosis of spontaneous pericardial and mediastinal emphysema the boy was prescribed bed rest in a semisitting position. Intravenous cefazolin sodium 3.0 g per day was started. A lOO-mg daily dose of intramuscular hydrocortisone sodium succinate was given for 2 days. The hospitalization
•
Radiographs. A) Demonstrating gentle line of air, corresponding heart borders, and vascular vessels. Pericardia! thickening is seen in right lower border of heart (arrowheads). B) Demonstrating presternal subcutaneous emphysema and free air in fascial spaces of neck (arrowhead). From the ENT Unit (Bartal, Zaarura) and the X-ray Department (Marvan), Poriya Government Hospital, Tiberias, Israel. REPRINTS - Nodar Bartal, MD, ENT Unit, Poriya Government Hospital, Tiberias, 15208, Israel.
1005
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 7, 2015
1006
Bartal et al, Imaging Case Study of the Month
mediastinum. From here it can decompress into the subcutaneous tissues, the deep cervical spaces, and eventually the pericardial space. I Other causes of the disease are direct trauma of the upper digestive tract, neoplasm disrupting the mucosal integrity of the esophagus, gas-producing infection, and even achalasia." The acute onset of retrosternal pain radiating to the back, neck, or shoulders is a usual clinical manifestation of the mediastinal phase of the disease. Mediastinal crepitation (Hamman's sign) is the classic physical finding at this stage. It may be accompanied by cardiac dullness on auscultation." When the air reaches the deep cervical spaces, pressure on the upper airway can create respiratory distress, as was the case with our patient.
If the process continues and dissecting air enters the pericardial space, cardiovascular dynamics may be compromised. Fatal tension pneumopericardium
with air cardiac tamponade has been reported.' The symptoms of mediastinal emphysema alone may mimic those of pericardial emphysema. Therefore, radiographic evidence of air in the pericardial space is the pathognomonic sign that must be present to establish conclusively the diagnosis of pneumopericardium." There are no pathognomonic electrocardiographic findings for pericardial emphysema, and the appearance of the echocardiogram can mimic that of pericardial effusion. 6 Spontaneous mediastinal and pericardial emphysema is almost always a self-limited condition. Treatment, which accompanies a diligent search for possible etiologic factors, consists of supportive measures: oxygen, analgesics, sedation, and careful monitoring. Most patients will recover within 1 to 2 weeks, as ours did.
REFERENCES 1. Aroesty J, Stenley RB Jr. Pneumomediastinum and cervical emphysema from the inhalation of "free base" cocaine. Otolaryngol Head Neck Surg 1986;94:372-4.
2. Harley H. Spontaneous cervical and mediastinal emphysema in asthma. Arch Otolaryngol Head Neck Surg 1987;113:11112. 3. Gapanavicius MG, Yellin A. Pneumomediastinum a complication of chlorine exposure from mixing household cleaning
agents. JAMA 1982;248:349-50. 4. Breatnach E, Han SY. Pneumopericardium occurring as a complication of achalasia. Chest 1986;90:292-3. 5. Gossage AAR, Robertson PW. Spontaneous pneumopericardium. Thorax 1976;31:460-5. 6. Luby BJ, Gerogiev M. Postpartum pneumopericardium. Obstet Gynecol 1983;62(suppl 3):465-505.
SPASTIC DYSPHONIA CONFERENCE The Voice Foundation will sponsor a state-of-the-art conference on Spastic Dysphonia, to be held July 20, 1991, at the Warwick Hotel in Philadelphia, Pennsylvania. For further information, contact The Voice Foundation, 1721 Pine Street, Philadelphia, PA 19103; (215) 735-7999.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 7, 2015
