Cardiovascular Journal of Africa: Vol 26 No 6 (November/December 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 6, November/December 2015 AFRICA e1
Case Report
Dyspnoea and chest pain as the presenting symptoms
of pneumomediastinum: two cases and a review of
the literature
Hasan Kara, Hasan Gazi Uyar, Selim Degirmenci, Aysegul Bayir, Murat Oncel, Ahmet Ak
Abstract
Pneumomediastinum is the presence of air in the mediasti-
num. It may occur as spontaneous, traumatic, or iatrogenic
pneumomediastinum. Although spontaneous pneumomedi-
astinum is usually observed in healthy young men, traumatic
pneumomediastinum may be caused by blunt or penetrating
trauma to the chest and neck. Pneumomediastinum is a clini-
cal condition with potential complications that cause high
morbidity and mortality rates. Pneumomediastinum also may
develop without tracheal or oesophageal injury after sponta-
neous or blunt chest, neck and facial injuries, and it may be
accompanied by pneumothorax.
We treated two patients who had pneumomediastinum.
Case 1 was a 20-year-old man who had pain and dyspnoea
around the sternum for one hour, as a result of a blow from
an elbow during a football match. Case 2 was a 23-year-old
man who had a two-day history of dyspnoea and chest pain
with no history of trauma. In both patients, diagnosis of
pneumomediastinum was confirmed with thoracic computed
tomography scans, and the condition resolved within five
days of in-patient observation. In conclusion, the diagnosis
of pneumomediastinum should be considered for all patients
who present to the emergency department with chest pain
and dyspnoea.
Keywords: trauma, spontaneous, mediastinum, emergency
department
Submitted 27/1/15, accepted 25/3/15
Published online 8/10/15
Cardiovasc J Afr 2015; 26: e1–e4
DOI: 10.5830/CVJA-2015-035
Pneumomediastinum, also known as mediastinal emphysema,
is the presence of air or other gas in the mediastinum.1
Pneumomediastinum can be categorised as traumatic,
spontaneous, or iatrogenic, and it also may be categorised as
spontaneous or secondary. Spontaneous pneumomediastinum
may occur in situations that increase alveolar pressure, such as
coughing, vomiting, straining, or Valsalva manoeuvre, which
may cause spontaneous rupture of the alveoli. These conditions
may occur with asthma, chronic obstructive pulmonary disease,
diabetic keto-acidosis, excessive exercise, cannabis or cocaine
intake, and diffuse interstitial fibrosis. In addition, severe
coughing that may cause mediastinal emphysema may occur
with pertussis, diphtheria, influenza, bronchiolitis, or acute
bronchitis in children.
Iatrogenic pneumomediastinum may develop after
tracheostomy induced by barotrauma during mechanical
ventilationor as a result of rupture of the tracheo-bronchial tree or
oesophagus during endoscopy. Traumatic pneumomediastinum
may occur as a result of blunt or penetrating chest, head or neck,
or eye injuries. 2,3
Traumatic and spontaneous pneumomediastinum have
similar symptoms, most commonly retrosternal chest pain
that begins acutely. In addition, common symptoms and signs
include neck pain, neck swelling, dyspnoea, cough, nasal voice,
dysphagia, anxiety, increased salivation, hoarseness and fever.
The clinical presentation is variable and may range from
vague symptoms to life-threatening respiratory failure. The
patient may have subcutaneous emphysema present in the neck
and chest, a Hamman sign with heart auscultation (crackling
sounds synchronous with the heartbeat), or cardiovascular
collapse.4
The purpose of this study was to report the experience
with two patients who had isolated pneumomediastinum that
presented with dyspnoea and chest pain.
Case reports
Case 1
A 20-year-old man had pain and dyspnoea around the sternum
for one hour as a result of a blow from an elbow during a football
match, and he was admitted to the emergency department. His
past medical history was non-contributory. The blood pressure
was 130/75 mmHg, pulse was 87 beats per minute, respiratory
rate was 16 breaths per minute, temperature was 36.9°C, and
transcutaneous oxygen saturation was 96% on room air. He had
Department of Emergency Medicine, Faculty of Medicine,
Selçuk University, Konya, Turkey
Hasan Kara, MD,
Hasan Gazi Uyar, MD
Selim Degirmenci, MD
Aysegul Bayir, MD
Ahmet Ak, MD
Department of Thoracic Surgery, Faculty of Medicine,
Selcuk University, Konya, Turkey
Murat Oncel, MD