Pneumomediastinum diagnostic study of choice

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2]

Overview

Pneumomediastinum can present with a various range of symptoms from sudden acute chest pain, shortness of breath, cough to no symptoms at all. Diagnosis of pneumomediastinum depends on the associated or precipitating condition. On physical exam, pneumomediastinum is associated with a specific sign known as Hamman’s sign, which is the presence of mediastinal crunch or click present on auscultation over the cardiac apex and the left sternal border synchronous with the heartbeat. Pneumomediastinum can routinely be diagnosed by chest X-ray. Diagnostic investigation of choice for pneumomediastinum is CT-scan of the chest.

Diagnostic Study of Choice

Study of choice

The diagnostic study of choice for pneumomediastinum is CT-scan of the chest.^[1]^[2]^[3]^[4]^[5]^[6]^[7]

Diagnostic results

The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum:

Subcutaneous emphysema
Naclerio V sign
- Seen in pneumomediastinum occurring often secondary to an esophageal rupture but it is not entirely specific to that condition.
Pneumopericardium
- Gas anterior to pericardium
Ring around artery sign
- Gas around pulmonary artery and main branches
Tubular artery sign
- Gas outlining major aortic branches
Double bronchial wall sign
- Gas outlining bronchial wall
Continuous diaphragm sign
- Gas trapped posterior to pericardium
Extrapleural sign
- Gas between parietal pleura and diaphragm
Gas in pulmonary ligament

Pediatric pneumomediastinum has different appearances:

Thymic wing sign
- Elevated thymus
Haystack sign (the heart appears like a haystack in a Monet painting)
- Gas crossing the superior mediastinum

Sequence of Diagnostic Studies

Sequence of diagnostic studies:^[8]^[9]^[10]^[11]

Symptomatic patient with the suspision of pneumomediastinum

Chest X-ray

Positive for pneumomediastinum

Inconclusive

No Known causative factor identified

Underlying pathological cause identified

CT chest

•Observe patient in the hospital
•Discharge if symptoms resolve
•Follow up until complete resolutution of symptoms

Treat underlying pathology

References

↑ Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA.
↑ Sandler, Carl M.; Llbshltz, Herman I.; Marks, Gerald; Libshitz, Herman I. (1975). “Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction”. Radiology. 115 (3): 539–540. doi:10.1148/15.3.539. ISSN 0033-8419.
↑ Kim, Hye Rin; Yoo, Seung Min; Lee, Hwa Yeon; Han, Jin Hee; Frazier, Aletta A; White, Charles S (2016). “Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum”. Acta Radiologica. 57 (12): 1483–1489. doi:10.1177/0284185116629830. ISSN 0284-1851.
↑ Moseley, John E. (1960). “Loculated Pneumomediastinum in the Newborn”. Radiology. 75 (5): 788–790. doi:10.1148/75.5.788. ISSN 0033-8419.
↑ Hammond DI (March 1984). “The “ring-around-the-artery” sign in pneumomediastinum”. J Can Assoc Radiol. 35 (1): 88–9. PMID 6725378.
↑ Levin, Bertram (1973). “The continuous diaphragm sign”. Clinical Radiology. 24 (3): 337–338. doi:10.1016/S0009-9260(73)80050-9. ISSN 0009-9260.
↑ Lillard, Richard L.; Allen, Parker (1965). “The Extrapleural Air Sign in Pneumomediastinum”. Radiology. 85 (6): 1093–1098. doi:10.1148/85.6.1093. ISSN 0033-8419.
↑ Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P (February 2015). “Pneumomediastinum”. J Thorac Dis. 7 (Suppl 1): S44–9. doi:10.3978/j.issn.2072-1439.2015.01.11. PMC 4332083. PMID 25774307.
↑ Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE (September 2008). “Spontaneous pneumomediastinum: a comparative study and review of the literature”. Ann. Thorac. Surg. 86 (3): 962–6. doi:10.1016/j.athoracsur.2008.04.067. PMID 18721592.
↑ Perna V, Vilà E, Guelbenzu JJ, Amat I (March 2010). “Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients”. Eur J Cardiothorac Surg. 37 (3): 573–5. doi:10.1016/j.ejcts.2009.08.002. PMID 19748792.
↑ Iyer VN, Joshi AY, Ryu JH (May 2009). “Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients”. Mayo Clin. Proc. 84 (5): 417–21. doi:10.1016/S0025-6196(11)60560-0. PMC 2676124. PMID 19411438.

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[1] Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA.

[SandlerLlbshltz1975-2] Sandler, Carl M.; Llbshltz, Herman I.; Marks, Gerald; Libshitz, Herman I. (1975). “Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction”. Radiology. 115 (3): 539–540. doi:10.1148/15.3.539. ISSN 0033-8419.

[KimYoo2016-3] Kim, Hye Rin; Yoo, Seung Min; Lee, Hwa Yeon; Han, Jin Hee; Frazier, Aletta A; White, Charles S (2016). “Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum”. Acta Radiologica. 57 (12): 1483–1489. doi:10.1177/0284185116629830. ISSN 0284-1851.

[Moseley1960-4] Moseley, John E. (1960). “Loculated Pneumomediastinum in the Newborn”. Radiology. 75 (5): 788–790. doi:10.1148/75.5.788. ISSN 0033-8419.

[pmid6725378-5] Hammond DI (March 1984). “The “ring-around-the-artery” sign in pneumomediastinum”. J Can Assoc Radiol. 35 (1): 88–9. PMID 6725378.

[Levin1973-6] Levin, Bertram (1973). “The continuous diaphragm sign”. Clinical Radiology. 24 (3): 337–338. doi:10.1016/S0009-9260(73)80050-9. ISSN 0009-9260.

[LillardAllen1965-7] Lillard, Richard L.; Allen, Parker (1965). “The Extrapleural Air Sign in Pneumomediastinum”. Radiology. 85 (6): 1093–1098. doi:10.1148/85.6.1093. ISSN 0033-8419.

[pmid25774307-8] Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P (February 2015). “Pneumomediastinum”. J Thorac Dis. 7 (Suppl 1): S44–9. doi:10.3978/j.issn.2072-1439.2015.01.11. PMC 4332083. PMID 25774307.

[pmid18721592-9] Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE (September 2008). “Spontaneous pneumomediastinum: a comparative study and review of the literature”. Ann. Thorac. Surg. 86 (3): 962–6. doi:10.1016/j.athoracsur.2008.04.067. PMID 18721592.

[pmid19748792-10] Perna V, Vilà E, Guelbenzu JJ, Amat I (March 2010). “Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients”. Eur J Cardiothorac Surg. 37 (3): 573–5. doi:10.1016/j.ejcts.2009.08.002. PMID 19748792.

[pmid19411438-11] Iyer VN, Joshi AY, Ryu JH (May 2009). “Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients”. Mayo Clin. Proc. 84 (5): 417–21. doi:10.1016/S0025-6196(11)60560-0. PMC 2676124. PMID 19411438.

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