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Spontaneous pneumomediastinum: clinical and natural history
E A Panacek1, A J Singer, B W Sherman
1Department of Emergency Medicine, University Hospitals of Cleveland, Ohio.
Study Objective:
To evaluate the clinical characteristics and natural history of patients presenting with spontaneous pneumomediastinum.
Design:
A retrospective case series was conducted to identify patients diagnosed with spontaneous pneumomediastinum. ICD-9 discharge codes were used for 1984 to 1990 at two institutions, and emergency department records of a third hospital were reviewed for 1981 to 1986. Clinical features, interventions, complications, setting, etiology, symptoms, and length of hospital stay were recorded.
Setting:
Three university tertiary care hospitals.
Participants:
All ED patients more than 12 years old with a diagnosis of spontaneous pneumomediastinum.
Interventions:
None.
Results:
Seventeen cases were identified. Age range was 15 to 41 years (mean, 25 years). Presenting symptoms were chest pain in eight (47%), dyspnea in three (18%), both symptoms in three (18%), and neither in three (18%). Three patients complained only of throat discomfort. Nine (52%) had a Hamman's crunch, 11 (65%) had subcutaneous emphysema, and two (11%) had a small pneumothorax. Five (29%) were smokers, and five (29%) had normal esophograms. Thirteen of 17 (76%) cases were associated with illicit inhalation drug use. Twelve cases (70%) had history of a "Valsalva-type" maneuver. All but three were admitted to a hospital, with a mean stay of 2.5 days (range, one to six). No patient suffered complications or required interventions for spontaneous pneumomediastinum. Specifically, no patient developed a subsequent pneumothorax or airway compromise. The three patients not admitted were followed up by telephone contact. All did well with rapid resolution of their symptoms.
Conclusion:
Most spontaneous pneumomediastinum cases occur in the setting of inhalational drug use. One hundred percent of patients will have a symptom directly related to the spontaneous pneumomediastinum, with 82% presenting with either dyspnea or chest pain. Most (88%) will present with either subcutaneous emphysema or a Hamman's crunch on examination. Simple spontaneous pneumomediastinum has a very benign course and does not require hospitalization. Serial radiographs, likewise, did not change the medical management of spontaneous pneumomediastinum.