Spontaneous primary pneumomediastinum: is it always benign?

Abstract

Background Spontaneous Pneumomediastinum is a rare disease. It could be a simple and self-limited condition or be a life-threatening complication of underlying diseases. The therapeutic options also differ by the cause. This systematic review was done to provide, as far as we know, the first attempt to broadly assess the clinical feature, predisposing factors, possible management, and outcome of spontaneous primary pneumomediastinum. Methods In addition to the two patients treated at our hospital, a Pub Med Search for literature on case reports of spontaneous pneumomediastinum published in English up to November 2018 was done. We extracted data on patients' demographic characteristics, symptoms, timing, diagnosis, management, and outcome of the treatment were analyzed based on the preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Result A total of 339 cases were reviewed. 71.7% of them were male. The Mean age affected was 22.4 ± 11.3 years. Chest pain, 196 (57.8%), is the most common presenting symptom, followed by dyspnea, 156 (46%), cough 95 (28%), neck swelling 92 (27.13%), cervical pain 88 (25.9%), dysphagia 39 (11.5%), odynophagia 37 (10.9%), and Dysphonia 14 (4.1%). Fifty-seven patients (16.8%) had a prior history of Asthma, 19 (5.6%) had Connective Tissue Disorders, and 12 (3.5%) had associated malignancy as an identified risk factor. In 35 (10.3%) patients, spontaneous pneumomediastinum was found incidentally. The mean number of days before the clinical resolution of spontaneous pneumomediastinum was 6.65 ± 11.8 days and the average hospital stay was 4.15 ± 1.93 days. Nineteen (5.6%) patients have died as a result of the underlying disease not related to SPM. Conclusion Spontaneous pneumomediastinum is uncommon, usually benign, a self-limited disorder that commonly occurs in a young adult without any apparent precipitating factor or disease. Spontaneous pneumomediastinum usually responds very well to conservative treatment without recurrence. However, secondary causes should be ruled out to minimize the unfavorable outcome.

Holocord spontaneous pneumorrhachis in the setting of refractory emesis

“…[15] In instances where pneumomediastinum, pneumothorax, perforated bowel or esophageal rupture have occurred, the proposed pathophysiology for development of PNR is tracking of air through the neural foramina into the spinal canal. [1,3] ere are no pathognomonic signs or symptoms associated with PNR. ere have been cases reported with neurological symptoms in the setting of iatrogenic and traumatic PNR secondary to cord compression.…”

“…A 2021 systematic review of the literature by Alemu et al that examined 339 pediatric and adult cases of spontaneous pneumomediastinum found PNR in 2.06% of cases. [1] In children, the incidence of PNR in a population of pediatric patients with spontaneous pneumomediastinum has been reported as high as 10%. [7] In our review of the literature for cases of truly spontaneous PNR without predisposing acute or chronic conditions (such as acute respiratory illness or asthma), we found that the location of the air most commonly found in the cervicothoracic spine, with the cervical spine, alone as the next most common location e predilection for the cervical spine has an anatomical explanation; there is no fascial barrier between the posterior mediastinum and the cervical epidural space.…”

“…Extradural location is most common. [ 1 ] While many cases have no definitive cause, the most commonly identified causes are trauma and iatrogenic introduction of air, either following a procedure accessing the spinal canal such as a lumbar puncture or spinal surgery, or as a complication due to procedures such as aberrant chest tube. [ 3 , 4 ] Additional risk factors for the development of PNR include asthma, inhalational drug use through increased in intrathoracic pressure (with cases documented following marijuana smoking and 3,4-methylenedioxymethamphetamine (“Ecstasy”) inhalation), sacral pressure sore, sacral myelomeningocele, enterocutaneous fistula, influenza, leukemia, diabetic ketoacidosis, infection with gas-producing organisms, respiratory infection (particularly by mycoplasma pneumoniae, respiratory syncytial virus or influenza), airway obstruction from foreign body aspiration, perforated bowel and/or esophagus, and weightlifting.…”

“…[ 15 ] In instances where pneumomediastinum, pneumothorax, perforated bowel or esophageal rupture have occurred, the proposed pathophysiology for development of PNR is tracking of air through the neural foramina into the spinal canal. [ 1 , 3 ]…”

“…When patients do have symptoms, they are often caused by associated conditions such as pneumomediastinum and subcutaneous emphysema causing chest pain, dyspnea, dysphagia and neck pain. [ 1 ] Treatment is aimed at symptomatic relief of symptoms of associated conditions, as described.…”