Hospital: Hospital Universitario de Guadalajara.
Ciudad:
Nº:
Aut@r o Autores: B. Sastre Borregon, J. Martinez Ollero, C. Marco Schulke, L. Gil Abadia, A. Joaquin Laguna.,
Presentación:
A 24-years-old male comes into the emergency room with an acute substernal pain for 3 hours. He also presents with dyspnea and cervical pain. No personal history. He refers cocaine abuse right before the onset of the clinic. A contrast enhanced cervicothoracic CT is performed. It shows an extensive pneumomediastinum, that tracks along the anterior side and around the trachea and the esophagus. The air goes through the vascular ramifications and the lung fissures. Additionally, there is gas in the subcutaneous tissue that dissects the musculature consistent with an extensive subcutaneous emphysema. It goes through the thoracic wall and the cervical region, affecting the submandibular and paraphafaringeal spaces. There are no signs of pathology at the tracheobronquial tree. With no history of previous trauma or surgery, the spontaneous pneumomediastinum is the first option of diagnosis, probably related to the cocaine abuse.
Discusión:
Pneumomediastinum is defined by the presence of extraluminal gas within the mediastinum. There are 2 different types: secondary and spontaneous. Secondary refers to trauma, surgery or mediastinal infections that lead to the presence of air. Spontaneous pneumomediastinum (SPM) is a diagnosis of exclusion, when no cause can be identified. Macklin and Macklin were the first describing the importance of the intrathoracic pressure leading to pneumomediastinum. When alveoli are distended against a closed glotis, such as smoking, inhalation or Valsalva maneuver, the alveoli may rupture into the interstitium and then into the mediastinum. SPM is an uncommon complication of cocaine abuse. It’s more frequent when the drug is smoked, but there are cases in the literature that occur when cocaine is insufflated. Clinical manifestations of pneumomediastinum are dysnea, chest pain, cough and neck pain. It usually includes subcutaneous emphysema of the neck and the chest.SPM management is conservatory with rest, pain control and follow-up, with an excellent prognosis. On the other hand, secondary pneumomediastinum is a severe life-threatening and in some cases it may need urgent surgery. Because of it, as radiologists we must rule out any source of secondary pneumomediastinum using another studies, like barium swallow, to dismiss esophaguel involvement.
Conclusión:
Pneumomediastinum is defined by the presence of extraluminal gas within the mediastinum. There are 2 different types: secondary and spontaneous. Secondary refers to trauma, surgery or mediastinal infections that lead to the presence of air. Spontaneous pneumomediastinum (SPM) is a diagnosis of exclusion, when no cause can be identified. Macklin and Macklin were the first describing the importance of the intrathoracic pressure leading to pneumomediastinum. When alveoli are distended against a closed glotis, such as smoking, inhalation or Valsalva maneuver, the alveoli may rupture into the interstitium and then into the mediastinum. SPM is an uncommon complication of cocaine abuse. It’s more frequent when the drug is smoked, but there are cases in the literature that occur when cocaine is insufflated. Clinical manifestations of pneumomediastinum are dysnea, chest pain, cough and neck pain. It usually includes subcutaneous emphysema of the neck and the chest.SPM management is conservatory with rest, pain control and follow-up, with an excellent prognosis. On the other hand, secondary pneumomediastinum is a severe life-threatening and in some cases it may need urgent surgery. Because of it, as radiologists we must rule out any source of secondary pneumomediastinum using another studies, like barium swallow, to dismiss esophaguel involvement.
Bibliografía:
– Pneumomediastinum from nasal insufflation of cocaine. Kloss B, Broton C, Rodriguez E. Int J Emerg Med. 2010 Dec, 3(4): 435–437. – Spontaneous pneumomediastinum: n extensive workup is not required.Bakhos CT, Pupovac SS, Ata A, Fantuzzi JP, Fabian T. J A