|Year : 2015 | Volume
| Issue : 1 | Page : 58-60
Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: An unusual presentation
Sreejith MG Nair, Veena Pinto, Veerendra K Hirebile, Roshan Maroli
Department of General Medicine, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
|Date of Web Publication||20-Jan-2015|
Sreejith MG Nair
Department of General Medicine, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka
Pneumomediastinum is defined as presence of air in mediastinum. Spontaneous pneumomediastinum (SPM) incidence ranges from 1:800 to 1:42000. It is more common in the young, tall males. Here we present a female aged 22 years, who presented to the casualty with sudden onset of breathlessness followed by pain around the neck and chest associated with dysphagia. She was a known asthmatic since several years on regular treatment. Respiratory system examination revealed bilateral polyphonic rhonchi. Chest radiograph revealed features of subcutaneous emphysema and pneumomediastinum. Computed tomography of the thorax confirmed the findings. She was diagnosed to have an exacerbation of bronchial asthma complicated by pneumomediastinum, probably due to alveolar rupture. She was managed with oxygen, bronchodilators, steroids and other supportive measures following which she improved. This case is being presented to emphasize the possibility of SPM as a rare complication of asthma exacerbation, showing good response to conservative management.
تتراوح معدلات حدوث تسرب الهواء في المنصف بين 008 : 1 إلى 0024 : 1 وهو أكثر شيوعًا بين الذكور الشباب طويلي القامة. يعرض الباحثون حالة لمريضة في الثانية والعشرين من العمر أدخلت لقسم الطوارئ تعاني من ضيق تنفس مفاجئ تبعه ألم حول العنق والصدر مصحوبًا بصعوبة في البلع. علمًا بأن المريضة مصابة بالربو. بين الفحص السريري للجهاز التنفسي كما وضحت صور الأشعة للصدر انتفاخ الرئتين وجود الهواء في المنصف وأكدتها الأشعة المقطعية. تم تشخيص حالة المريضة على أنها مضاعفات للربو بسبب تمزق الحويصلات الهوائية. تم علاج المريض بالأوكسجين والكلورتيزون وموسعات الشعب الهوائية. تحسنت حالة المريض بعد العلاج. تبين هذه الحالة إمكانية حدوث تسرب الهواء التلقائي في المنصف (MPS) كمضاعفة نادرة للربو المتفاقم والذي استجاب للعلاج التحفظي.
Keywords: Bronchial asthma, pneumomediastinum, subcutaneous emphysema
|How to cite this article:|
Nair SM, Pinto V, Hirebile VK, Maroli R. Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: An unusual presentation. Saudi J Med Med Sci 2015;3:58-60
|How to cite this URL:|
Nair SM, Pinto V, Hirebile VK, Maroli R. Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: An unusual presentation. Saudi J Med Med Sci [serial online] 2015 [cited 2019 Sep 17];3:58-60. Available from: http://www.sjmms.net/text.asp?2015/3/1/58/149684
| Introduction|| |
Pneumomediastinum is defined as the presence of air in the mediastinum, also known as mediastinal emphysema.  It can develop spontaneously or following trauma. Spontaneous pneumomediastinum (SPM) incidence varies widely, ranging from 1 in 800 to 1 in 42,000 adult and pediatric patients admitted to a hospital. It is more common in young, tall males with a male to female ratio of 8:1. , The most common presentation is pleuritic chest pain and dyspnea. Other common symptoms are dysphagia, pain around neck and dysphonia. Examination usually shows features suggestive of subcutaneous emphysema. It is evaluated clinically and by radiographic evaluation (X-ray and computed tomography [CT] chest). SPM responds well to medical line of management with no recurrence in most cases.
| Case report|| |
A 22-year-old female presented to the emergency room with a 2-day history of breathlessness, associated with wheezing and one episode of vomiting, followed by neck pain and pain over upper part of the chest. She also gave a history of dysphagia for the past 2 days. She was a known case of bronchial asthma on regular bronchodilator therapy since past 1 year. Patient was admitted and evaluated. On admission, patient was tachypneic and blood pressure, pulse rate, arterial oxygen saturation were within normal limits. General examination revealed features suggestive of subcutaneous emphysema around the neck and upper part of chest. Her calculated body mass index (BMI) was 21. Chest X-ray revealed air trapping in the subcutaneous tissue of the neck. Patient was diagnosed to have subcutaneous emphysema and further evaluation including CT thorax revealed pneumomediastinum [Figure 1] [Figure 2] [Figure 3] [Figure 4]. Barium swallow studies were normal. She was diagnosed to have an exacerbation of bronchial asthma complicated with pneumomediastinum, probably due to alveolar rupture. She was managed medically with oxygen supplementation, nebulization and other supportive care. Gradually her vitals stabilized.
|Figure 1: Computed tomography-chest sagittal section shows pneumomediastinum and subcutaneous emphysema.|
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|Figure 2: Computed tomography-chest coronal view showing pneumomediastinum.|
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|Figure 4: Computed tomography-scout view showing pneumomediastinum and subcutaneous emphysema.|
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| Discussion|| |
Subcutaneous emphysema and SPM are rare complications of asthma exacerbation. The etiology behind this is probably ruptures of marginal alveoli due to sudden increase in intra-alveolar pressure (asthma, valsalva maneuver, cough, emesis, barotrauma). This leads to rupture of small alveoli into the surrounding bronchovascular sheath.  Less commonly, pneumomediastinum results from air escaping from the upper respiratory tract, intrathoracic airways, or gastrointestinal tract. The air leakage into the interstitial space, mediastinum and subcutaneous cervicofacial space results in ventilation-perfusion mismatch. This patient was a known asthmatic; she came with features of pneumomediastinum due to rupture of alveoli. Her calculated BMI score was 21 and no clinical features of anorexia, so it excludes causes like anorexia nervosa, which is considered as a predisposing factor for both spontaneous pneumothorax and mediastinum. Different studies showed that SPM may constitute as a complication in anorexia nervosa patients, even if they did not exhibit purging behavior.  Spontaneous pneumothorax also may be associated with low BMI and consequently malnutrition and nutrient deficiency. ,
In uncomplicated SPM, the physical examination is normal in up to 30% of cases. , Subcutaneous emphysema is one of the commonest signs in pneumomediastinum. It is usually detected over the neck or precordial area and is highly specific for SPM.  Subcutaneous emphysema is usually demonstrated by palpation. Pneumomediastinum characteristically gives a positive Hammans sign, which is a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium, and usually associated with muffling of heart sounds. , Most common presentation is pleuritic chest pain, dyspnea, odynophagia and subcutaneous emphysema. Sometimes it may be associated with distended neck veins if the escaped air compromises venous return (tension pneumomediastinum). Newcomb and Clarke reported neck pain in 2 out of 18 patients with SPM.  Uncomplicated SPM is managed conservatively with analgesics, rest and avoidance of maneuvers that increase pulmonary pressure.  SPM is a benign condition and it usually resolves without complication in 2-15 days. Recurrences are uncommon in most cases. All patients should be counseled adequately to avoid Valsalva maneuvers and activities predisposing to barotraumas.
| Conclusion|| |
This study concludes that SPM is a rare complication of exacerbation of asthma and it shows a good response to conservative management.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]