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Mediastinal Emphysema: Aetiology, Diagnosis, and Treatment

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Mediastinal Emphysema: Aetiology, Diagnosis, and Treatment Thorax: first published as 10.1136/thx.21.4.325 on 1 July 1966. Downloaded from Thorax (1966), 21, 325. Mediastinal emphysema: aetiology, diagnosis, and treatment J. M. GRAY AND G ILLIAN C. HANSON F om Whipps Cross Hospital, London E.lJ, and the Obstetric Unit, Forest Gate Hospital, London E.lJ Mediastinal emphysema is a condition frequently Macklin (1944) thought that this condition arose omitted in the differential diagnosis of retrosternal following rupture of marginal alveoli producing chest pain; it is generally benign but on occasions pulmonary interstitial emphysema and later can be fatal. Little has been written about this pneumomediastinum. The cause of rupture is condition, and, although rare, it has probably been difficult to establish; but rupture probably does misdiagnosed or has not been detected in the past. not occur unless one at least of the following is present: overinflation, relative increase of intra- pulmonary pressure as compared with that on the AETIOLOGICAL CLASSIFICATION chest wall, or decreased pulmonary circulation. Gordon (1936) and Kjaergaard (1933) maintained 1. Rupture of marginal alveoli into the pul- that ruptured blebs caused spontaneous pneumo- monary interstitial tissue and thence to the thorax despite the fact that in many of the cases mediastinum which came to necropsy no ruptured pleural blebs 2. Mixed aetiological factors (The mode of were found. Scott (1957) stated that usually a production is not yet certain.) pneumothorax is produced by rupture of an (a) Spontaneous pneumomediastinum alveolus or bulla directly through the visceral (b) Trauma to the chest wall pleura, and he postulated that air might enter the http://thorax.bmj.com/ 3. Air entering the mediastinum from the deep mediastinum by passing through the mediastinal fascial planes of the neck pleura from the pleural cavity. 4. Air entering the mediastinum from the retroperitoneal space Trauma to the chest wall The mechanism of 5. Perforation of the trachea, bronchus, or mediastinal emphysema following closed chest oesophagus into the mediastinum injuries is uncertain. The most likely cause is compression of one part of the chest followed by RUPTURE OF MARGINAL ALVEOLI INTO PULMONARY increased intra-alveolar pressure and rupture of on October 4, 2021 by guest. Protected copyright. INTERSTITIAL TISSUE some alveoli, with development of pulmonary interstitial emphysema followed by mediastinal The mechanism of production of pulmonary emphysema. interstitial emphysema of the lungs and its spread into the mediastinum has been described by AIR ENTERING MEDIASTINUM FROM DEEP FASCIAL Macklin and Macklin (1944). They emphasized PLANES OF THE NECK (Forbes, Salmon, and that a pressure gradient must exist between the Herweg, 1947; Work, 1943) This may be the alveolus and the underlying connective tissue so path followed during thyroidectomy or tonsillec- that air can pass from the alveolus into the tomy and in deep wounds of the neck. However, tissues. in thyroidectomy and tonsillectomy a raised intra- Pneumomediastinum follows the development alveolar pressure secondary to outlet airway of pulmonary interstitial emphysema, since air obstruction may be the primary factor, air tends to follow the path of least resistance and entering the mediastinum from the lung travels along the vascular sheaths to the hilus. interstices. MIXED AETIOLOGICAL FACTORS AIR ENTERING MEDIASTINUM FROM RETROPERITONEAL SPACE If air accumulates in the retroperitoneum Spontaneous pneumomediastinum Macklin and it may travel alongside the aorta or the oesophagus 325 Thorax: first published as 10.1136/thx.21.4.325 on 1 July 1966. Downloaded from 326 J. M. Gray and Gillian C. Hanson into the mediastinum. This may follow perfora- CLINICAL FEATURES The most common symptom tion of the stomach or intestine or may occur of mediastinal emphysema is pain, and the after perirenal insufflation. important clinical findings are subcutaneous emphysema predominantly in the neck, oblitera- PERFORATION OF TRACHEA, BRONCHUS, OR OESO- tion of the cardiac dullness, and peculiar sounds PHAGUS INTO MEDIASTINUM Disease or trauma audible over the heart. In addition to these occasionally causes rupture of the trachea or features there may be evidence of pneumothorax. bronchi. Rupture of the trachea may be caused Mediastinal emphysema may arise when the by a sudden increase of pressure in the tracheo- patient is at rest and may be symptomless, or the bronchial tree against a closed glottis or as a patient may notice some swelling and/or crepitus result of a shearing force (Rubin and Rubin, in the neck. Subcutaneous emphysema may be the 1961). Rupture of the oesophagus may be due to only clinical evidence for the presence of pneumo- a large number of causes, the site of the rupture mediastinum. Frequently the patient givies a depending on the aetiology. Pen2trating wounds history of coughing, vomiting, or sudden exertion. generally involve the cervical oesophagus and Pain is a frequent complaint ; it is usually retro- rarely produce mediastinal emphysema. Foreign sternal and may radiate to the shoulders and bodies often lodge in the oesophagus at the level down both arms; it is sharp and aggravated by of the aortic arch crossing the left main bronchus. inspiration and sometimes by swallowing. In addi- Instrumentation remains the most frequent tion, there is usually a feeling of oppression or cause of oesophageal rupture (Anderson, 1952; constriction often associated with dyspnoea. Smith and Tanner, 1956). With a diseased oeso- Hamman (1945) attributed the retrosternal pain phagus the most common site of rupture is at to distension and dissection of the mediastinal that level, but when not diseased the rupture tissues with air. generally takes place at the narrowest point in Subcutaneous emphysema may be the only the oesophagus, namely at or just below the clinical evidence for the presence of pneumo- pharyngo-oesophageal orifice. mediastinum and is due to air dissecting upwards In spontaneous rupture the site involved is between the fascial layers of the neck (Hollins- generally in the lower 8 cm. of the oesophagus head, 1962). It is often detectable initially as a http://thorax.bmj.com/ and is usually a vertical tear on the left superficial crackling sound when a stethoscope is posterolateral wall. Several explanations have applied to the chest wall or neck. The apex beat been giv;en for this site. First, the left side of the may not be palpable, the cardiac dullness is oesophagus is not supported by connective tissue, diminished or absent, and the heart sounds are and, secondly, there appears to be an intrinsic distant. Hamman's sign (Hamman, 1934, 1937) weakness in the muscle wall at this point was at one time thought to be diagnostic of (Mackler, 1952). Increased intraluminal pressure mediastinal emphysema (Hamman, 1937, 1939; within the oesophagus plays an important part in Muller, 1888). The sign is present in 50%0 of cases rupture of the lower third, and rupture may arise (Sulavik, 1962) but may also be heard in left- on October 4, 2021 by guest. Protected copyright. in labour (Kennard, 1950), during severe sided pneumothorax (Scott, 1957), dilated lower asthmatic seizures (Mitchell, Derbes, and Aken- oesophagus, bullous emphysema of the lingular head, 1955), during strenuous exercise (Griffith, segments, pneumoperitoneum with a high left 1932), and after vomiting secondary to increased diaphragm, and gastric dilatation (Sulavik, 1962). intracranial pressure (Cushing, 1932; Fincher and The sounds arz generally heard best along the left Swanson, 1949). Many patielnts, however, give sternal edge, third to sixth intercostal space, they histories suggestive of previous gastro-intestinal may vary in intensity and are intensified when the disease, peptic ulcer, alcoholism, or gluttony. patient is sitting up or lying in the left lateral Barrett (1946) postulated that the cricopharyngeal decubitus position. The sounds occur synchro- sphincter in these patients fails to relax during the nously with the heart beat, are 'crunching' in attempt at vomiting, and this, most often asso- character (Hamman, 1937), and are generally ciated with a full stomach, raises the pressure associated with systole but may be heard in within the oesophagus sufficiently high to produce diastole. If these sounds are heard in the presence rupture. of subcutaneous emphysema of the chest wall or In most instances rupture of the oesophagus is neck, then mediastinal emphysema from whatever probably the result of multiple factors, including cause can be diagnosed. Pneumothorax is a fre- incoordination, weakness of the oesophageal wall, quent accompaniment. This is generally small and and an increased pressure within the oesophagus. left-sided and occurs in one-third of cases of Thorax: first published as 10.1136/thx.21.4.325 on 1 July 1966. Downloaded from Mediastinal emphysema: aetiology, diagnosis, and treatment 327 pneumomediastinum (Hamman, 1945). Tension rupture is the chest radiograph, and that if this pneumothorax may develop, and, since the lung is taken early it may show localized mediastinal is splinted by interstitial air, the size of the emphysema in the lower part of the medistinum pneumothorax may have no relation to the before the development of generalized mediastinal intrapleural pressure (Nicholas, 1958). and/or subcutaneous emphysema, hydrothorax, Spontaneous mediastinal emphysema is generally or hydropneumothorax. In the neck, the radio- a benign condition which subsides with no graph may show on
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