Spontaneous Pneumomediastinum in a Young Female.

Dear Editor,

Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum without antecedent pathological condition or secondary to events, such as trauma, surgical procedures, foreign body ingestion, or labor in pregnancy.[12] Here, we report a rare case of SPM presenting with respiratory distress and dysphagia.

A 16-year-old girl presented to our emergency department with dry cough for 1 month and retrosternal chest pain and shortness of breath for 10 days. Supine posture was associated with increased bouts of cough followed by shortness of breath. She also had difficulty in swallowing both solid and liquid foods. There was no history of long-standing fever, weight loss, anorexia or night sweats, chest or neck trauma, dental treatment, or foreign body ingestion. No history of tuberculosis or bronchial asthma could be elicited and the symptoms pointed toward an allergic etiology. Primary survey and detailed examination, including blood investigations, were within normal limits. Posteroanterior chest X-ray revealed extraluminal translucency around the trachea, suggesting pneumomediastinum [Figure 1]. Thoracic and neck contrast-enhanced computed tomography (CT) confirmed the presence of mediastinal emphysema with narrowing of middle of esophagus, but no signs of pneumothorax or fluid collections [Figure 2]. There were no parenchymal or lymphatic lesions on CT suggestive of tuberculosis. Upper gastrointestinal endoscopy (UGIE) was apparently normal, showed no lesion inside esophagus, and pneumomediastinum was suggested as a cause of dysphagia. There was a dramatic resolution of dysphagia after the procedure. Postendoscopy period was uneventful, and after few days of observation, the patient was discharged with a diagnosis of SPM.

Figure 1

Posterior-anterior chest radiograph showing pneumomediastinum (red arrows)

Figure 2

(a) Computed tomography of thorax (sagittal plane), showing mediastinal emphysema (red arrows), at the level of bifurcation of trachea (blue arrows). No evidence of pneumothorax. (b) Computed tomography of thorax (coronal plane), showing mediastinal emphysema (red arrows), at the level of sixth thoracic spine. Normal bronchi are shown with blue arrows

Pneumomediastinum (mediastinal emphysema) is divided into two subgroups: spontaneous, i.e., without any antecedent cause and secondary due to an underlying pathology, leading to barotrauma and esophageal rupture. The most common presenting symptoms are chest pain and dyspnea, with the most common sign being surgical emphysema. Air in mediastinum causes compression of airways and esophagus, leading to respiratory distress and dysphagia, respectively. The prognosis of SPM is good with resolution in most cases.[345] Recurrence is rare, and if an accompanying severe complication like mediastinitis or sepsis ensues, it may lead to death.[67] In our case, SPM healed spontaneously, mediastinal air got absorbed with time, and the patient became symptom free within 2 weeks. She was able to take food after endoscopy, which suggested that UGIE fulfilled therapeutic purpose to open the compressed esophagus. The patient was followed up for a month and found to be stable, symptom free, and healthy.

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