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ThefirsteletrocnicJournalofOtolaryngology
oftheworld
ISSN15161528

449

Year:2007Vol.11Num.3Jul/Set(16)

Section:CaseReport
Author(s):
SpontaneousRetropharyngealEmphysemaand LidianeMariadeBrito
Pneumomediastinum MacedoFerreira1,rikFrota
Haguette2

Keywords:
Mediastinalemphysema.Subcutaneousemphysema.Cough.

Abstract:

Introduction:Spontaneouspneumomediastinumandretropharyngeal
emphysemaarerareclinicalentities.Theseconditionsarecausedbyone
supportedincreaseoftheintraalveolarandintrabronchialpressurewithair
dissectingalongtheperivascularspacesofthemediastinum.Paininthethroat,in
theneckanddisfagiaisthepredominantsymptoms.Aim:Ourobjectivein
describingthisincasethatitweretoshowtotheimportanceofthedistinguishing
diagnosisindyspneacasesandOdinophagia,andalertingthespecialistforthe
evolutionofthispathology.CaseReport:Wereportacasepresentingascough
andspontaneousretropharyngealemphysemaandpneumomediastinum,inwoman
of42yearswholookedmedicalattendancewithcomplaintofintenseOdinophagia.
Conclusion:TheSpontaneouspneumomediastinumisrareclinicalentity,
generallypresentsspontaneousinvolutionandgoodprognostic,asitwasthecase
forustold.

INTRODUCTION

Spontaneous pneumomediastinum is clinically rare, affecting around 1 in every 7001200

patients in hospital(1). The main causes reported in the literature are due to intense physical
activities, labour, pulmonary barotrauma, deep diving or snorkling, intense cough, cocaine
inhalation,vommiting,conculsions(2,3,4).AretrospectivestudycarriedinanAmericanHospital
showedthatthemaincauseofpneumomediastinumwasduetodruginhalation(5).

The air in the air passages can undergo pressure raise and dissect pharynx, causing cervical
subcutaneousemphysema,pneumomediastinumandevenpneumopericardium.

The case described reveals importance due to its rarity and its semiology. The target of this
study is to describe a rare complication of the increase of intrathoraxical pressure with
dissectionofsuperficialplainshavingcoughasaconsequenceandalsotoalarmspecialistsfor
suchdiagnosisonemergencycases.

CLINICALCASE

KMTC,female,42,Caucasian,searchedforERcomplainingofintenseodynophagia,cervicalgia
and pain on interscapular area which became worse when inhaling. She had felt those for 12
hours,andallwascausedbyirritativedrycoughwhichhadstarted3daysbefore.

She did not have fever, adynamia or expectoration, denied tobbaco, alcohol and drug use,
chronicaldiseases,traumasorrecentsurgeries.

Physical exam presented anxiety, pains and limited cervical movements. Vital signs were
stable.Shepresentedlighthyperemiaoforopharinxposteriorwallandlightbulgingonbilateral
anteriorinferior cervical area which would crepitate when touched, and indirect laryngoscopy

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with no alterations. The cardiac auscultation revealed creptations which were syncronic to
cardiacsystole(HammanSign)andthepulmonaryauscultationwasnormal.

Xray from the thorax and cervical area showed the presence of pneumomediastinum,
pneumopericardium, pretracheal subcutaneous emphysema and presence of air on
retropharyngealspace.

Patient was treated with painkillers and oxygen, remained under watching for three hours and
was released from hospital after improvement of symptoms (she did not need hospitalization
due to the absence of a more serious problem). She was under observation for around three
hours,withrelativeimprovementofthesymptomsandgoodevolution.Theuseofoxygenwas
necessary, maily as hospital routine for cases of dyspnea, despite patient presented goog
oxygen saturation. As she did not present either clinical, radiological signs of infection nor
normothermia,noantibioticsorantiinflammatoriesoranykindofmedicationweresuggested.

Patientisunderclinicalobservationandhasnotpresentedanynewsymptomsforthreeyears.

DISCUSSION

Subcutaneous emphysema associated to pneumomediastinum was first described in 1850 by

Knott,inpatientswithcoughepisodes(3).Sincethen,theorieshavebeensuggestedinorderto
explain its physiopathology. Marcklin suggested that intraalveolar hypertension caused by
sudden and repeated glottic closing and air passage obstruction would lead to a breakage of
terminal alveolus increasing intrathoracic pressure. Its consequence would be a flowout of
suchairpreviouslyrepressedinthealveolustotheinterstitialpulmonaryspaceanddissection
through the vascular spaces which would lead the air to the mediastinum. Morere, in 1966,
suggestedthatcoughwouldunbalancecapillarylungpressure.Alveolarbreakageandairgoing
into interstice, would cause dissection through vascular planes and eventually towards
mediastinum.Athirdoptionwouldbethebreakageoflikely preexisting subpleural bubbles or
cysts. In general terms, therefore, there really is an increase of pressure on the alveolus by
leadinganairlowout(2,3).

The clinical condition is related to lung symptoms, and 82% of patients present dyspnea or
thoraxpain.Theothersymptomspressedthroatfellingodynophagianeckpainordysphagia
shortterm back, shoulder or neck pain and then worsened by inspiration. Around 88% of
patients present subcutaneous emphysema and/or Harman sign at physical exam.
Subcutaneous emphysema can extend through neck, face, tongue, axilla, arms and chest.
Theremaybeabafamentodascardiacmurmursandofprecordialpercussion.Hamman sign is
featured by the presence of estertores or syncronic creptations with the auscultation of the
cardicmurmursontheprecordium(5,6).

Theradiologicalstudyofcervicalandthoraxareasconfirmthepresenceofairinparapharynx
andmediastinum.Itisimportanttorememberthelateralincidenceofit,though50%ofpatients
with pneumomediastinum are not detected on anteriorposterior incidence6. Esophagus exam
withbariumcanbeusedinordertoavoidpossibleesophagusbreakageasbeingthecauseof
pneumomediastinum.Inastudywith36cases,theimportanceofradiographywastakenasthe
maindiagnosismethod(7).

Kirchner points out six important steps on pneumomediastinum diagnosis: substernal pain
subcutaneous or retroperitoneal emphysema abafamento of cardiac murmurs Hamman sign
mediastinumpressureincreasewithdyspnea,cyanosis,venousingurgitationorbloodcirculation
failure,andradiologicalevidencesofaironthemediastinum(6).Despiteallthat,itisnecessary
tobesuspicioustodiagnose(7).

In general terms, this condition is selflimited, and conservative procedures are enough for its
therapy. Pain killers and 100% oxygen are basically the procedures to be taken when
necessary.Therefore,someliteraturesshowthatoxygenisnotnecessary.Mostoftimeoxygen
saturationissatisfactoryandtheuseofpainkillersisenoughtosoothepainandmuscletension.
Occasionaltherapyshouldbedone(6).

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Figure1.SimpleprofilecervicalXrayexamwhichrevealsretropharyngeal
emphysema.

Figure2.SimplechestanteriorposteriorXrayexamwhichreveals
pneumomediastinum.

Figure3.SimplechestprofileXrayexamwhichrevealsanterior
pneumomediastinum.

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CONCLUSION

This is an important differential diagnosis to be done at ER, as it can be wrongly

taken by infection, allergic and even neoplasm processes, and patients can present
sudden and intense symptoms. Despite the condition of symptoms, it is selflimited
andbenign,andtherapyissimpleandevenpalliative.Correctandpreviousdiagnosis,
though,cankeeppatientcalmanditisalsolessexpensiveforhospitals.

REFERENCES

1.SleemanD,TurnerR.Spontaneouspneumomedistinumwithalterationinvoice.J
LaryngolOtol1989103:12223.

2. Wiesner B Frey M. Spontanes Pneumomediastinum bei Asthma bronchiale.

SchweizRundschMedPrax200695(10):36973.

3. Parker GS, Mosborg DA, Foley RW, Stiernberg CM. Spontaneous cervical and
mediastinalemphysema.Laryngoscope1990100:93840.

4. Avaro JP, DJourno XB, Hery G, Marghli A, Doddoli C, Peloni JM, et al.
Pneumomdiastin spontan du jeune adulte: Ferreira LMBM une entit clinique
bnigne.RevMalRespir200623(1Pt1):7982.

5. Chujo M, Yoshimatsu T, Kimura T, Uchida Y, Kawahara K Spontaneous

pneumomediastinum.KyobuGeka200659(6):4648.

6. Jabourian Z, McKenna EL, Feldman M. Spontaneous pneumomediastinum and

subcutaneousemphysema.JOtolaryngol198817:503.

7.CampilloSotoA,CollSalinasA,SoriaAledoV,BlancoBarrioA,FloresPastor
B, CandelArenas M, et al. Neumomediastino espontneo: estudio descriptivo de
nuestraexperienciabasadaen36casos.ArchBronconeumol200541(9):52831.

1.ResidentENTDoctoratHospitalGeraldeFortalezaCE.
2. ENT Doctor Head of ENT Resident doctor program at Hospital Geral de
FortalezaCE.

HospitalGeraldeFortalezaCE(GeneralHospitalCEBrazil)

LidianeFerreira
Address: Av Washington Soares, 5353 bloco 4, apto. 202 Fortaleza/CE CEP:
60830030Fax:(85)34866400Email:lidianembm@yahoo.com.br

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