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== Overview == | == Overview == | ||
Pneumomediastinum can present with a various range of symptoms from sudden acute chest pain, | Pneumomediastinum can present with a various range of symptoms from sudden [[Chest pain|acute chest pain]], [[Dyspnea|shortness of breath]], [[cough]] to no symptoms at all. Diagnosis of pneumomediastinum depends on the associated or precipitating condition. On physical exam, pneumomediastinum is associated with a specific sign known as [[Hamman's sign]], which is the presence of mediastinal crunch or click present on [[auscultation]] over the [[Apex of the heart|cardiac apex]] and the [[left sternal border]] synchronous with the [[Heart sounds|heartbeat]]. Pneumomediastinum can routinely be diagnosed by [[chest X-ray]]. Diagnostic investigation of choice for pneumomediastinum is [[Computed tomography|CT-scan]] of the chest. | ||
== Diagnostic Study of Choice == | == Diagnostic Study of Choice == | ||
=== Study of choice === | === Study of choice === | ||
The diagnostic study of choice for pneumomediastinum is CT-scan of the chest. | The diagnostic study of choice for pneumomediastinum is [[Computed tomography|CT-scan]] of the chest.<ref>{{cite book |title=Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA}}</ref><ref name="SandlerLlbshltz1975">{{cite journal|last1=Sandler|first1=Carl M.|last2=Llbshltz|first2=Herman I.|last3=Marks|first3=Gerald|last4=Libshitz|first4=Herman I.|title=Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction|journal=Radiology|volume=115|issue=3|year=1975|pages=539–540|issn=0033-8419|doi=10.1148/15.3.539}}</ref><ref name="KimYoo2016">{{cite journal|last1=Kim|first1=Hye Rin|last2=Yoo|first2=Seung Min|last3=Lee|first3=Hwa Yeon|last4=Han|first4=Jin Hee|last5=Frazier|first5=Aletta A|last6=White|first6=Charles S|title=Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum|journal=Acta Radiologica|volume=57|issue=12|year=2016|pages=1483–1489|issn=0284-1851|doi=10.1177/0284185116629830}}</ref><ref name="Moseley1960">{{cite journal|last1=Moseley|first1=John E.|title=Loculated Pneumomediastinum in the Newborn|journal=Radiology|volume=75|issue=5|year=1960|pages=788–790|issn=0033-8419|doi=10.1148/75.5.788}}</ref><ref name="pmid6725378">{{cite journal |vauthors=Hammond DI |title=The "ring-around-the-artery" sign in pneumomediastinum |journal=J Can Assoc Radiol |volume=35 |issue=1 |pages=88–9 |date=March 1984 |pmid=6725378 |doi= |url=}}</ref><ref name="Levin1973">{{cite journal|last1=Levin|first1=Bertram|title=The continuous diaphragm sign|journal=Clinical Radiology|volume=24|issue=3|year=1973|pages=337–338|issn=00099260|doi=10.1016/S0009-9260(73)80050-9}}</ref><ref name="LillardAllen1965">{{cite journal|last1=Lillard|first1=Richard L.|last2=Allen|first2=Parker|title=The Extrapleural Air Sign in Pneumomediastinum|journal=Radiology|volume=85|issue=6|year=1965|pages=1093–1098|issn=0033-8419|doi=10.1148/85.6.1093}}</ref> | ||
===== Diagnostic results ===== | ===== Diagnostic results ===== | ||
The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum: | The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum: | ||
*Subcutaneous emphysema | *[[Subcutaneous emphysema]] | ||
*Naclerio V sign | *Naclerio V sign | ||
*Gas anterior to pericardium | **Seen in pneumomediastinum occurring often secondary to an [[Boerhaave syndrome|esophageal rupture]] but it is not entirely specific to that condition. | ||
*Gas around pulmonary artery and main branches | *[[Pneumopericardium]] | ||
*Gas outlining major aortic branches | **Gas anterior to [[pericardium]] | ||
*Gas outlining bronchial wall | *Ring around artery sign | ||
*Continuous diaphragm sign | **Gas around [[Pulmonary artery|pulmonary artery and main branches]] | ||
*Gas between parietal pleura and diaphragm | *Tubular artery sign | ||
*Gas in pulmonary ligament | **Gas outlining major [[Aorta|aortic branches]] | ||
Pediatric pneumomediastinum | *Double bronchial wall sign | ||
*Elevated thymus | **Gas outlining [[Bronchus|bronchial wall]] | ||
* | *Continuous [[Diaphragm (anatomy)|diaphragm]] sign | ||
**Gas trapped posterior to [[pericardium]] | |||
*Extrapleural sign | |||
**Gas between [[parietal pleura]] and diaphragm | |||
*Gas in [[pulmonary ligament]] | |||
Pediatric pneumomediastinum has different appearances: | |||
*Thymic wing sign | |||
**Elevated [[thymus]] | |||
*Haystack sign (the heart appears like a haystack in a Monet painting) | |||
**Gas crossing the [[superior mediastinum]] | |||
===== Sequence of Diagnostic Studies ===== | ===== Sequence of Diagnostic Studies ===== | ||
Sequence of diagnostic studies<ref name="pmid25774307">{{cite journal |vauthors=Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P |title=Pneumomediastinum |journal=J Thorac Dis |volume=7 |issue=Suppl 1 |pages=S44–9 |date=February 2015 |pmid=25774307 |pmc=4332083 |doi=10.3978/j.issn.2072-1439.2015.01.11 |url=}}</ref><ref name="pmid18721592">{{cite journal |vauthors=Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE |title=Spontaneous pneumomediastinum: a comparative study and review of the literature |journal=Ann. Thorac. Surg. |volume=86 |issue=3 |pages=962–6 |date=September 2008 |pmid=18721592 |doi=10.1016/j.athoracsur.2008.04.067 |url=}}</ref><ref name="pmid19748792">{{cite journal |vauthors=Perna V, Vilà E, Guelbenzu JJ, Amat I |title=Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients |journal=Eur J Cardiothorac Surg |volume=37 |issue=3 |pages=573–5 |date=March 2010 |pmid=19748792 |doi=10.1016/j.ejcts.2009.08.002 |url=}}</ref><ref name="pmid19411438">{{cite journal |vauthors=Iyer VN, Joshi AY, Ryu JH |title=Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients |journal=Mayo Clin. Proc. |volume=84 |issue=5 |pages=417–21 |date=May 2009 |pmid=19411438 |pmc=2676124 |doi=10.1016/S0025-6196(11)60560-0 |url=}}</ref> | Sequence of diagnostic studies:<ref name="pmid25774307">{{cite journal |vauthors=Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P |title=Pneumomediastinum |journal=J Thorac Dis |volume=7 |issue=Suppl 1 |pages=S44–9 |date=February 2015 |pmid=25774307 |pmc=4332083 |doi=10.3978/j.issn.2072-1439.2015.01.11 |url=}}</ref><ref name="pmid18721592">{{cite journal |vauthors=Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE |title=Spontaneous pneumomediastinum: a comparative study and review of the literature |journal=Ann. Thorac. Surg. |volume=86 |issue=3 |pages=962–6 |date=September 2008 |pmid=18721592 |doi=10.1016/j.athoracsur.2008.04.067 |url=}}</ref><ref name="pmid19748792">{{cite journal |vauthors=Perna V, Vilà E, Guelbenzu JJ, Amat I |title=Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients |journal=Eur J Cardiothorac Surg |volume=37 |issue=3 |pages=573–5 |date=March 2010 |pmid=19748792 |doi=10.1016/j.ejcts.2009.08.002 |url=}}</ref><ref name="pmid19411438">{{cite journal |vauthors=Iyer VN, Joshi AY, Ryu JH |title=Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients |journal=Mayo Clin. Proc. |volume=84 |issue=5 |pages=417–21 |date=May 2009 |pmid=19411438 |pmc=2676124 |doi=10.1016/S0025-6196(11)60560-0 |url=}}</ref> | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | | | | A01 | | | |A01= Symptomatic patient with the suspision of pneumomediastinum}} | {{Family tree | | | | | | | | | | A01 | | | |A01= Symptomatic patient with the suspision of pneumomediastinum}} | ||
{{Family tree | | | | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | | | | B01 | | | |B01= Chest X-ray}} | {{Family tree | | | | | | | | | | B01 | | | |B01= Chest X-ray}} | ||
{{Family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | }} | {{Family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | }} | ||
{{Family tree | | | | C01 | | | | | | | | | | C02 |C01= Positive for | {{Family tree | | | | C01 | | | | | | | | | | C02 |C01= Positive for pneumomediastinum| C02= Inconclusive}} | ||
{{Family tree | |,|-|-|^|-|-|.| | | | | | | | |!| | | | | }} | {{Family tree | |,|-|-|^|-|-|.| | | | | | | | |!| | | | | }} | ||
{{Family tree | |!| | | | | |!| | | | | | | | |!| | | | | }} | {{Family tree | |!| | | | | |!| | | | | | | | |!| | | | | }} | ||
{{Family tree | D01 | | | | D02 | | | | | | | D03 |D01= No Known causative factor identified| D02= Underlying pathological cause identified| D03=CT chest}} | {{Family tree | D01 | | | | D02 | | | | | | | D03 |D01= No Known causative factor identified| D02= Underlying pathological cause identified| D03=CT chest}} | ||
{{Family tree | |!| | | | | |!| | | | | }} | {{Family tree | |!| | | | | |!| | | | | }} | ||
{{Family tree | |!| | | | | |!| | | | | }} | {{Family tree | |!| | | | | |!| | | | | }} | ||
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{{familytree/end}} | {{familytree/end}} | ||
==References== | |||
{{Reflist|2}} | |||
[[Category:Pulmonology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Cardiology]] | |||
[[Category:Medicine]] | |||
[[Category:Surgery]] | |||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 15:12, 11 February 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2]
Overview
Pneumomediastinum can present with a various range of symptoms from sudden acute chest pain, shortness of breath, cough to no symptoms at all. Diagnosis of pneumomediastinum depends on the associated or precipitating condition. On physical exam, pneumomediastinum is associated with a specific sign known as Hamman's sign, which is the presence of mediastinal crunch or click present on auscultation over the cardiac apex and the left sternal border synchronous with the heartbeat. Pneumomediastinum can routinely be diagnosed by chest X-ray. Diagnostic investigation of choice for pneumomediastinum is CT-scan of the chest.
Diagnostic Study of Choice
Study of choice
The diagnostic study of choice for pneumomediastinum is CT-scan of the chest.[1][2][3][4][5][6][7]
Diagnostic results
The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum:
- Subcutaneous emphysema
- Naclerio V sign
- Seen in pneumomediastinum occurring often secondary to an esophageal rupture but it is not entirely specific to that condition.
- Pneumopericardium
- Gas anterior to pericardium
- Ring around artery sign
- Gas around pulmonary artery and main branches
- Tubular artery sign
- Gas outlining major aortic branches
- Double bronchial wall sign
- Gas outlining bronchial wall
- Continuous diaphragm sign
- Gas trapped posterior to pericardium
- Extrapleural sign
- Gas between parietal pleura and diaphragm
- Gas in pulmonary ligament
Pediatric pneumomediastinum has different appearances:
- Thymic wing sign
- Elevated thymus
- Haystack sign (the heart appears like a haystack in a Monet painting)
- Gas crossing the superior mediastinum
Sequence of Diagnostic Studies
Sequence of diagnostic studies:[8][9][10][11]
| Symptomatic patient with the suspision of pneumomediastinum | |||||||||||||||||||||||||||||||||||||||||||
| Chest X-ray | |||||||||||||||||||||||||||||||||||||||||||
| Positive for pneumomediastinum | Inconclusive | ||||||||||||||||||||||||||||||||||||||||||
| No Known causative factor identified | Underlying pathological cause identified | CT chest | |||||||||||||||||||||||||||||||||||||||||
•Observe patient in the hospital •Discharge if symptoms resolve •Follow up until complete resolutution of symptoms | Treat underlying pathology | ||||||||||||||||||||||||||||||||||||||||||
References
- ↑ Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA.
- ↑ Sandler, Carl M.; Llbshltz, Herman I.; Marks, Gerald; Libshitz, Herman I. (1975). "Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction". Radiology. 115 (3): 539–540. doi:10.1148/15.3.539. ISSN 0033-8419.
- ↑ Kim, Hye Rin; Yoo, Seung Min; Lee, Hwa Yeon; Han, Jin Hee; Frazier, Aletta A; White, Charles S (2016). "Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum". Acta Radiologica. 57 (12): 1483–1489. doi:10.1177/0284185116629830. ISSN 0284-1851.
- ↑ Moseley, John E. (1960). "Loculated Pneumomediastinum in the Newborn". Radiology. 75 (5): 788–790. doi:10.1148/75.5.788. ISSN 0033-8419.
- ↑ Hammond DI (March 1984). "The "ring-around-the-artery" sign in pneumomediastinum". J Can Assoc Radiol. 35 (1): 88–9. PMID 6725378.
- ↑ Levin, Bertram (1973). "The continuous diaphragm sign". Clinical Radiology. 24 (3): 337–338. doi:10.1016/S0009-9260(73)80050-9. ISSN 0009-9260.
- ↑ Lillard, Richard L.; Allen, Parker (1965). "The Extrapleural Air Sign in Pneumomediastinum". Radiology. 85 (6): 1093–1098. doi:10.1148/85.6.1093. ISSN 0033-8419.
- ↑ Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P (February 2015). "Pneumomediastinum". J Thorac Dis. 7 (Suppl 1): S44–9. doi:10.3978/j.issn.2072-1439.2015.01.11. PMC 4332083. PMID 25774307.
- ↑ Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE (September 2008). "Spontaneous pneumomediastinum: a comparative study and review of the literature". Ann. Thorac. Surg. 86 (3): 962–6. doi:10.1016/j.athoracsur.2008.04.067. PMID 18721592.
- ↑ Perna V, Vilà E, Guelbenzu JJ, Amat I (March 2010). "Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients". Eur J Cardiothorac Surg. 37 (3): 573–5. doi:10.1016/j.ejcts.2009.08.002. PMID 19748792.
- ↑ Iyer VN, Joshi AY, Ryu JH (May 2009). "Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients". Mayo Clin. Proc. 84 (5): 417–21. doi:10.1016/S0025-6196(11)60560-0. PMC 2676124. PMID 19411438.