Management and Outcomes of Spontaneous Pneumomediastinum in Children

Abstract

Objectives: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes.Methods: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. Results:We identified 183 patients with spontaneous pneumomediastinum.The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinalassociated pneumomediastinum (31, 17%), and secondary respiratoryassociated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information.Conclusions: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Boy with crackling neck

“…A conservative approach should be considered in well appearing patients, presenting without respiratory distress, with normal vital signs, normal oxygen saturation and adequate pain control. After a 4 h brief observation in the emergency department, the patient can be discharged planning a clinical follow‐up 5 ; no X‐ray control for asymptomatic patients should be considered 6 . Our patient was successfully managed with this approach without any further complication.…”

Pneumomediastinum and subcutaneous emphysema: a rare cause of odynophagia

“…Spontaneous pneumomediastinum is rare in the paediatric population. Secondary spontaneous pneumomediastinum is often associated with a respiratory tract infection or an asthma exacerbation, as in this case 1–4. Clinical presentation includes more frequently chest pain and cough 3.…”

“…Secondary spontaneous pneumomediastinum is often associated with a respiratory tract infection or an asthma exacerbation, as in this case 1–4. Clinical presentation includes more frequently chest pain and cough 3. Other reported symptoms are dyspnoea, neck pain, odynophagia, dysphagia, neck and upper chest swelling, torticollis, dysphonia, abdominal or back pain 2 5.…”

“…Other reported symptoms are dyspnoea, neck pain, odynophagia, dysphagia, neck and upper chest swelling, torticollis, dysphonia, abdominal or back pain 2 5. Odynophagia has been recently reported in 31% of cases with spontaneous pneumomediastinum and in 7% of respiratory-associated pneumomediastinum cases 3…”

“…Radiographic characteristic signs of spontaneous pneumomediastinum include the ‘spinnaker sign’, in which the thymic lobes are seen deviating upwards and outwards, the ‘continuous diaphragm sign’, in which the mediastinal gas is seen as a thin lucent line outlining the superior surface of the diaphragm and separating it from the heart, and the ‘Naclerio’s V sign’, in which the gas outlines the lateral margin of the descending aorta and extends laterally over left hemidiaphragm 5. Chest CT may be helpful for evaluation of any associated causes or abnormalities and to exclude life-threatening differential diagnoses 3 5 6…”