8
2
Fig 2
for pneum6 omediastinum and subcutaneous cervical em-
physema
Chest radiograph of a 20
month-old boy showing
subcutaneous cervical em-
physema and pneumomedi-
astinum (white arrows)
The clinical diagnosis is based on the symptom triad17 of
dyspnoea, chest pain and subcutaneous emphysema. It
is also based on Hamman’s sign which consist of a
crunching rasping sound, synchronous with the heart
beat and best heart over the preco8rdium with patient on
1
the left lateral decubitus position. Our patient met most
of the diagnostic features except for pain which we
could not confirm because of the age of the patient;
however, we think the patient had pain because of the
irritability that was present at presentation.
On the basis of the history, examination and radiological
findings, a diagnosis of bronchopneumonia complicated
by pneumomediastinum and subcutaneous cervical em-
physema was made. He was admitted into the paediatric
ward and commenced on intravenous antibiotics and
high flow oxygen. He made remarkable improvement
with comthplete resolution of subcutaneous emphysema
The diagnosis of pneumomediastinum and subcutaneous
cervical emphysema can be made clinically; however, it
is pertinent that imaging studies be done for confirma-
tion. Chest radiography (although not invariably) reveal
a pneumomediastinum and co-existing disease (e.g
pneumonia, pneumothorax). Another diagnostic tool is
chest computerized tomographic scan which may be
used to diagnose pneumomediastinum not visualized on
chest radiography. It has been reported that up to 30% of
patient presenting with mild pneumome1d9 iastinum could
be missed with chest radiography alone.
on the 4 day of admission. He was discharged on the
th
7
day after completing the full course of intravenous
antibiotics and followed up on a monthly basis for eight
months without recurrence and was subsequently dis-
charged from clinic.
The management of pneumomediastinum and subcuta-
neous cervical emphysema is largely conservative as
spontaneous absorption of air occurs within two week .
Discussion
2
This process however can be enhanced by breathing
high concentration of oxygen. Reassurance, observation
and analgesia as well as treating the underlying cause
are all that is needed in most cases. Our patient re-
sponded on the fourth day of admission following anti-
biotics and oxygen 2t0herapy. Although recurrence rate is
reported to be low, we still followed up our patient for
a reasonable period of time.
Pneumomediastinum and subcutaneous cervical emphy-
sema,9 are unusual complications of childhood pneumo-
8
nia. Most cases of pneumomediastinum result from
alveolar rupture with subsequent air leak into the sur-
1
1
rounding bronchovascular sheath. Because the mean
pressure in the mediastinum is always less than the pres-
sure in the pulmonary parenchyma, the free air tends to
move centripetally along the vascular sheaths, perhaps
facilitated by the pumping action of breathing. The air
dissects to the hilum, and spreads into the mediastinum
or through the loose me12diastinal fascia to the subcutane-
ous tissues of the neck.
Conclusion
Pneumomediastinum and subcutaneous cervical emphy-
sema can be caused by a large and diverse group of fac-
tors especially respiratory manoeuvres that produce high
intrathoracic pressure such as valsalva manoeuvre,
coughing, vigorous crying and forceful retching or vom-
Pneumomediastinum and subcutaneous cervical emphy-
sema in this index case constituted an unusual but very
important complication of childhood pneumonia which
is amenable to conservative treatment. It was therefore
important to report this case to raise awareness amongst
clinicians so as to avoid unnecessary surgical decom-
pression that may worsen the situation.
1
3
iting . Respiratory tract infections ( e.g bronchopneu-
monia, bronchiolitis, laryngotracheitis ) have been im-
plicated in the development of pneumomediastinum and
subcutaneous cervical emphysema especially in associa-
2
tion with asthma, and the organisms that had been found
Conflict of interest: None
Funding: None
in previous reports include mycoplasma pneumonia,
influenza A (H1N1) virus and Pneumocys14ti,1c5,j1u6roveci ( in
the HIV exposed or infected children).
Although
there was a clear evidence of an infection in our patient
giving the presenting symptoms and the elevated white
cell count, we could not however isolate the particular
organism due to laboratory inadequacies. Obstructive
lung diseases (e.g Asthma, foreign body aspiration,
bronchopulmonary dysplasia) especially in intubated
and mechanically ventilated patient are also risk factors
Acknowledgement
We want to sincerely appreciate Dr Damijo Henry and
the unit Nurses for their dedication and support.