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Pneumomediastinum and Subcutaneous Cervical Emphysema

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Pneumomediastinum and Subcutaneous Cervical Emphysema Niger J Paed 2014; 41 (1):81 –83 CASE REPORT Okposio MM Pneumomediastinum and Unior MO subcutaneous cervical emphysema: unusual complications of childhood pneumonia DOI:http://dx.doi.org/10.4314/njp.v41i1,16 Accepted: 8th September 2012 Abstract The occurrence of the mediastinum resulting in life pneumomediastinum and subcuta- threatening complications. There- ( ) Okposio MM neous cervical emphysema as fore, adequate knowledge of these Unior MO Department of Paediatrics, complications of childhood pneu- conditions and their proper man- Mariere Memorial Central Hospital monia is very unusual. They re- agement is very important for cli- Ughelli, Delta State, Nigeria sults most often from respiratory nicians. Mariere Memorial Central Hospital manoeuvres that produce high Ughelli, Delta State, intrathoracic pressure. Although Keywords : Subcutaneous Cervical Nigeria. they are largely benign, pneu- Emphysema, Pneumomediasti- Tel: +2348034042120 momediastinum can cause com- num, Childhood, Pneumonia Email: [email protected] pression of major blood vessels in Introduction four days for which the parents were administering medication bought over the counter. He has not been Pneumomediastinum, otherwise known as mediastinal diagnosed with asthma and this was the first episode of emphysema refers to the presence of free air within the difficulty with breathing. There was no history of chest mediastinum while subcutaneous cervical emphysema wall trauma or of any gastrointestinal disorder. refers to the presence of air in the subcutaneous tissue of On physical examination, the patient was noted to be the neck. 1 These clinical entities are uncommon in pae- very irritable and markedly dyspnoeic, with flaring of diatric practice with an overall prevalence ranging be- the alae nasi and subcostal and intercostals recessions. tween 1 in 800 and 1 in 42000 patients seen at the emer- He was febrile with a temperature of 38.7 oC. He had a gency department. 2 Mediastinal and subcutaneous cervi- diffuse anterior neck swelling extending to both clavicu- cal emphysema may occur spontaneously, or secondary lar areas and the upper chest wall with crepitus on palpa- to trauma or pathological disease state 3, with gastroin- tion. (Fig 1) His respiratory rate was 56 breaths per min- testinal and respiratory diseases most commonly impli- ute and an oxygen saturation of 89% on room air. There cated. 4,5 were crackles on both middle and lower lung zones. His heart rate was 160 beats per minute and heart sounds The respiratory disease commonly associated with pneu- were normal. In addition, there was an associated momediastinum and subcutaneous cervical emphysema “mediastinal crunch” ( Hamman’s Sign). Chest x-ray is bronchial asthma. 6 Pneumonia, though a very com- showed a widespread perihilar and bibasal opacities in mon childhood respiratory system morbidity known to keeping with bronchopneumonia. It also revealed be associated with several complications 7 is very rarely streaky and bubbly lucencies in the mediastinal, supra- implicated in the occurrence of pneumomediastinum and clavicular and chest wall region confirming subcutane- subcutaneous cervical emphysema. 8,9 Although, these ous emphysema and a pneumomediastinum (fig 2). clinical conditions are largely benign, pneumomediasti- Laboratory investigation showed an elevated white cell num can cause compression of major blood vessels in count of 20,000 mm 3, the electrolytes and urea were the mediastinum resulting in life threatening complica- essentially normal. Other investigations done included tions. 10 It was therefore important to report this case in HIV testing for both patient and mother after appropriate order to highlight its clinical presentation, radiological pre-test counselling and the results were negative features and the management options. Fig 1 Case Report Photograph showing diffuse anterior neck O.B, a 20- month old boy was brought to our emergency swelling due to subcuta- neous emphysema department with a history of increasing difficulty with breathing and progressive anterior neck swelling which started a few hours before presentation. He had had a fever, cough and mild difficulty with breathing for about 82 Fig 2 for pneumomediastinum and subcutaneous cervical em- Chest radiograph of a 20 physema 6 month-old boy showing subcutaneous cervical em- The clinical diagnosis is based on the symptom triad of physema and pneumomedi- dyspnoea, chest pain and subcutaneous emphysema. 17 It astinum (white arrows) is also based on Hamman’s sign which consist of a crunching rasping sound, synchronous with the heart beat and best heart over the precordium with patient on 18 the left lateral decubitus position. Our patient met most of the diagnostic features except for pain which we could not confirm because of the age of the patient; On the basis of the history, examination and radiological however, we think the patient had pain because of the findings, a diagnosis of bronchopneumonia complicated irritability that was present at presentation. by pneumomediastinum and subcutaneous cervical em- physema was made. He was admitted into the paediatric The diagnosis of pneumomediastinum and subcutaneous ward and commenced on intravenous antibiotics and cervical emphysema can be made clinically; however, it high flow oxygen. He made remarkable improvement is pertinent that imaging studies be done for confirma- with complete resolution of subcutaneous emphysema tion. Chest radiography (although not invariably) reveal on the 4 th day of admission. He was discharged on the a pneumomediastinum and co-existing disease (e.g 7th day after completing the full course of intravenous pneumonia, pneumothorax). Another diagnostic tool is antibiotics and followed up on a monthly basis for eight chest computerized tomographic scan which may be months without recurrence and was subsequently dis- used to diagnose pneumomediastinum not visualized on charged from clinic. chest radiography. It has been reported that up to 30% of patient presenting with mild pneumomediastinum could be missed with chest radiography alone. 19 The management of pneumomediastinum and subcuta- neous cervical emphysema is largely conservative as Discussion 2 spontaneous absorption of air occurs within two week . Pneumomediastinum and subcutaneous cervical emphy- This process however can be enhanced by breathing sema are unusual complications of childhood pneumo- high concentration of oxygen. Reassurance, observation nia. 8,9 Most cases of pneumomediastinum result from and analgesia as well as treating the underlying cause alveolar rupture with subsequent air leak into the sur- are all that is needed in most cases. Our patient re- rounding bronchovascular sheath. 11 Because the mean sponded on the fourth day of admission following anti- biotics and oxygen therapy. Although recurrence rate is pressure in the mediastinum is always less than the pres- 20 sure in the pulmonary parenchyma, the free air tends to reported to be low, we still followed up our patient for move centripetally along the vascular sheaths, perhaps a reasonable period of time. facilitated by the pumping action of breathing. The air dissects to the hilum, and spreads into the mediastinum or through the loose mediastinal fascia to the subcutane- ous tissues of the neck. 12 Conclusion Pneumomediastinum and subcutaneous cervical emphy- sema can be caused by a large and diverse group of fac- Pneumomediastinum and subcutaneous cervical emphy- tors especially respiratory manoeuvres that produce high sema in this index case constituted an unusual but very intrathoracic pressure such as valsalva manoeuvre, important complication of childhood pneumonia which coughing, vigorous crying and forceful retching or vom- is amenable to conservative treatment. It was therefore iting 13 . Respiratory tract infections ( e.g bronchopneu- important to report this case to raise awareness amongst monia, bronchiolitis, laryngotracheitis ) have been im- clinicians so as to avoid unnecessary surgical decom- plicated in the development of pneumomediastinum and pression that may worsen the situation. subcutaneous cervical emphysema especially in associa- tion with asthma, 2and the organisms that had been found in previous reports include mycoplasma pneumonia , Conflict of interest: None influenza A (H1N1) virus and Pneumocystic juroveci ( in Funding: None the HIV exposed or infected children). 14,15,16 Although there was a clear evidence of an infection in our patient giving the presenting symptoms and the elevated white cell count, we could not however isolate the particular organism due to laboratory inadequacies. Obstructive Acknowledgement lung diseases (e.g Asthma, foreign body aspiration, bronchopulmonary dysplasia) especially in intubated We want to sincerely appreciate Dr Damijo Henry and and mechanically ventilated patient are also risk factors the unit Nurses for their dedication and support. 83 References 1. Maunder RJ, Pierson DJ, Hudson 9. Yalaburgi SB. Subcutaneous and 16. Rosen DJ, Blasberg RC, Ashton LD. Subcutaneous and mediastinal mediastinal emphysema associated CP et al. Spontaneous pneumome- emphysema: pathophysiology, with childhood measles. S Afr Med diastinum in pneumocystis pneu- diagnosis and management. Arch J 1980; 38: 521-525 monia and Acquired Immunodefi- Intern Med 1984; 144: 1447-1453 10. Miguil M, Chekairi A. Pneumome- ciency Syndrome. The Internet 2. Chalumeau M, Le Clainche L, diastinum and pneumothorax asso- Journal of Pulmonary Medicine . Sayeg N et al. Spontaneous
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