Correct answer: B
Discussion
The chest CT shows extensive pneumomediastinum with air extending
from the pneumomediastium into the paraesophageal soft tissues, neck,
axillae, and paraspinal soft tissues with a small amount extending into
the spinal canal (pneumorrhachis). The patient was treated with
bronchodilators and steroids for an acute asthma exacerbation and
conservative medical management (bed rest, analgesia, oxygen) for
pneumomediastinum. Symptoms and physical exam dramatically improved
within 24 hours, and he was discharged home with close follow-up
arranged.
Spontaneous pneumomediastinum is a rare condition that occurs when
air enters the mediastinal cavity without a clear inciting event, such
as trauma. This condition is most often seen in thin, young men who are
smokers or in patients with underlying pulmonary disease (most commonly
asthma). The most common presenting symptoms include chest pain and
dyspnea1. The pathophysiology of spontaneous
pneumomediastinum is thought to involve either the rupture of
tracheobronchial or esophageal mucosal barriers, or alveolar rupture
with resultant air escape into the respiratory interstitium with travel
of air along a pressure gradient towards the mediastinum.2
Pneumorrhachis, which is usually found in conjunction with air
collections in other body cavities, is defined as the presence of air in
the intraspinal space. This rare condition is most often caused by
trauma or iatrogenic causes (such as epidural anesthesia and lumbar
puncture), but there are case reports of its association with
pneumomediastinum associated with acute asthma exacerbations. In these
cases, air likely tracks from the posterior mediastinum into the
posterior epidural space, as there are no fascial barriers separating
these structures.3
Although rare complications like pneumopericadium may occur, spontaneous pneumomediastinum generally follows a benign
course with treatment of the underlying condition, rest, and analgesia.4 Similarly, in most cases of
non-traumatic pneumorrhachis, the air resorbs spontaneously into the circulation over time.3
Although neurologic complications beyond mild headache are unlikely to occur, patients should be counseled to seek
further medical care if they begin to experience neurologic deficits as more aggressive interventions may be warranted
at that time.
References
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Sahni S, Verma J, Grullon J, Esquire A, Patel P, Talwar, A. Spontaneous pneumomediastinum: Time for consensus. N Am J Med Sci 2013;5: 460-4.
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Macklin MT, Macklin CC. Malignant interstitial emphysema of the lungs
and mediastinum as an important occult complication in many respiratory
diseases and other conditions: interpretation of the clinical
literature in the light of laboratory experiment. Medicine 1944; 23: 281-358.
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Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum,
pneumopericardium and subcutaneous emphysema as complications of
bronchial asthma. Ann Thorac Med 2009; 4: 143-5.
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Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothoracic Sug 2007; 31:1110-14.
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Oertel MF, Korinth MC, Reinges MHT, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis, and management of pneumorrhachis. Eur Spine J 2006;15:S636-S643.