Síndrome de Hamman. Reporte de un caso

El síndrome de Hamman se caracteriza por la presencia de aire libre en el espacio intersticial del mediastino, asociado a enfisema subcutáneo. Se presenta el caso de un paciente masculino de 19 años de edad, remitido al Servicio de Cirugía General del Hospital General Docente Leopoldito Martínez, por presentar disnea de moderada intensidad, acompañada de aumento súbito de volumen del cuello y región anterior del tórax, posterior a un acceso de tos durante una crisis aguda de asma bronquial. Al examen físico se identificó enfisema subcutáneo en cuello, tórax, pared anterior del abdomen y miembros superiores. Se observó signo de Hamman positivo. Se indicó radiografía y tomografía axial computadorizada simple de tórax, que evidenció el enfisema subcutáneo y el neumomediastino. Se concluyó como un síndrome de Hamman. El tratamiento fue conservador y la evolución satisfactoria. Este síndrome es una entidad poco frecuente y autolimitada, que se presenta generalmente en pacientes jóvenes masculinos, aparentemente sanos. El diagnóstico se define por los estudios de imaginología y el tratamiento conservador es el recomendado. Se presenta este caso con el objetivo de exponer la presentación, diagnóstico y tratamiento de este síndrome.

Hamman's syndrome is characterized by the presence of free air in the interstitial space of the mediastinum, associated with subcutaneous emphysema. The case of a 19-years-old male patient, referred to the General Surgery Service of the Leopoldito Martínez General Teaching Hospital, presenting with moderate intensity dyspnea, accompanied by a sudden increase in volume of the neck and anterior region of the thorax, after a coughing fit during an acute attack of bronchial asthma is presented. The physical examination identified subcutaneous emphysema in the neck, thorax, anterior wall of the abdomen and upper limbs. A positive Hamman sign was observed. Chest X-ray and simple computed tomography were indicated, showing subcutaneous emphysema and pneumomediastinum. It was concluded as a Hamman syndrome. The treatment was conservative and the evolution was satisfactory. Hamman's syndrome is a rare and self-limiting entity that generally occurs in young, apparently healthy male patients. The diagnosis is defined by imaging studies and conservative treatment is recommended. This case is presented with the aim of exposing the presentation, diagnosis and treatment of this syndrome.

Enfisema mediastínico como complicación de una crisis asmática en paciente joven con COVID-19

El COVID-19 es el virus causante de la pandemia actual, su método de transmisión es aéreo y su tropismo por el aparato respiratorio hace que las personas con patologías de base a nivel pulmonar sean más susceptibles. En este caso produjo una exacerbación del asma bronquial y una complicación rara de éste es el neumomediastino.

COVID-19 is a virus that caused the current pandemic. Its airborne transmission and tropism for the respiratory system make people with lung-based pathologies more susceptible. In this case, it not only produced an exacerbation of bronchial asthma, but also pneumomediastinum, a rare complication of asthma.

Neumomediastino secundario a efecto Macklin: a propósito de un caso / Pneumomediastinum secondary to Macklin effect: a case report

RESUMEN Introducción: el neumomediastino es la presencia de aire en el espacio mediastinal procedente de bronquios, alvéolos o de una ruptura esofágica, que viaja a través de las vainas vasculares y los planos tisulares hacia el espacio mediastinal; puede ser categorizado como espontáneo, traumático o secundario. Objetivo: describir un paciente con neumomediastino secundario al efecto Macklin. Caso clínico: se trata de un paciente masculino de 32 años sin antecedentes médicos, que acude a urgencias refiriendo tos seca, dolor de garganta, dolor al ingerir alimentos, malestar general, dolores articulares a predominio de rodillas y espalda baja y fiebre de 39°C acompañada de escalofríos. El día posterior a su ingreso, tras un acceso de tos, presenta de forma súbita aumento de volumen del cuello y porción superior del tórax, acompañado de dolor en dicha zona, dificultad para respirar y hablar. Al examen en este momento se constata aumento de volumen y crepitación en cuello, fosa supraclavicular, y porción anterosuperior y posterosuperior del tórax (enfisema subcutáneo) así como estertores roncos y sibilantes diseminados en ambos campos pulmonares. Se realiza radiografía de tórax de urgencia que muestra signos sugestivos de enfisema subcutáneo y neumomediastino. Se solicita valoración por servicio de cirugía General y otorrino, los cuales sugieren tratamiento conservador. Conlusiones: el neumomediastino es una enfermedad poco frecuente y benigna, sus características clínicas son dolor torácico y enfisema subcutáneo luego de un acceso de tos y evoluciona de forma satisfactoria entre dos y 15 días.

ABSTRACT Introduction: pneumomediastinum is the presence of air in the mediastinal space coming from bronchi, alveoli or esophageal rupture, which travels through vascular sheaths and tissue planes to the mediastinal space; it can be categorized as spontaneous, traumatic or secondary. Objective: to describe a patient with pneumomediastinum secondary to the Macklin effect. Case report: a 32-year-old male patient with no medical history came to the emergency room with a dry cough, sore throat, pain when eating and general malaise, joint pain predominantly in the knees and lower back, and fever of 39°C with chills. The day after his admission, after an attack of coughing, he suddenly presented an increase in volume of the neck and upper chest, accompanied by pain in this area, difficulty in breathing and speaking. On examination at this time, there was an increase in volume and crepitus in the neck, supraclavicular fossa, and anterosuperior and posterosuperior portion of the thorax (subcutaneous emphysema) as well as hoarse and wheezing rales disseminated in both lung fields. An emergency chest X-ray was performed showing signs suggestive of subcutaneous emphysema and pneumomediastinum. An evaluation by the General Surgery and Otorhinolaryngology Departments was requested, which suggested conservative treatment. Conclusions: pneumomediastinum is a rare and benign disease, its clinical characteristics are chest pain and subcutaneous emphysema after a coughing fit and it evolves satisfactorily between 2 and 15 days.

Síndrome de Hamman: a propósito de un caso / Hamman Syndrome, a case study / Sindrome de Hamman, relato de caso

Introducción: el síndrome de Hamman es la aparición de neumomediastino espontáneo asociado a enfisema, patología poco frecuente en pediatría. Sus síntomas principales son dolor torácico agudo, disnea y enfisema subcutáneo. Objetivo: describir una experiencia clínica en la que se sospechó este síndrome analizando el proceso diagnóstico, estudios complementarios y el tratamiento. Caso clínico: varón de 4 años, con antecedentes personales de laringitis a repetición. Presenta laringitis aguda severa, requirió ventilación no invasiva por 12 horas. A las 24 horas del ingreso instaló de forma brusca estridor inspiratorio, dificultad respiratoria, edema de cuello y cara con crepitación a nivel de cuello y cara anterior del tórax que se fue extendiendo a ambos brazos. Se realiza radiografía de tórax que evidencia enfisema subcutáneo extenso. Se realiza tomografía de cuello y tórax que descarta lesión en vía aérea. Con el planteo de síndrome de Hamman en un niño que presentaba como factor predisponente el episodio de laringitis aguda, se decidió no continuar con estudios complementarios. Se realizó tratamiento fisiopatológico con buena evolución clínica. Alta a la semana del ingreso. Conclusiones: el diagnóstico en la urgencia del neumomediastino espontáneo puede representar un desafío, con una variedad de diagnósticos diferenciales potencialmente mortales. La alta sospecha permitirá realizar una evaluación clínica e imagenológica adecuada que permitan confirmar su diagnóstico y evitar procedimientos invasivos innecesarios.

Introduction: Hamman's syndrome involves the appearance of spontaneous pneumomediastinum associated with emphysema, a rare pathology in pediatrics. Its main symptoms include acute chest pain, dyspnea and subcutaneous emphysema. Objective: to describe a clinical case of this suspected syndrome by analyzing the diagnostic process, supplementary studies, and treatment. Clinical case: 4-year-old male with personal history of repeated laryngitis. He presented severe acute laryngitis, requiring non-invasive ventilation for 12 hours. Twenty-four hours after admission he developed abrupt inspiratory stridency, respiratory distress, neck, and face edema with crepitation at neck level and front of thorax spreading to both arms. A chest X-ray shows extensive subcutaneous emphysema. A neck and chest CT scan rules out airway injury. With the suggestion of Hamman's syndrome in a child who presented acute laryngitis as a predisposing factor the episode, it was decided not to continue with additional studies. Physio-pathological treatment was carried out with good clinical evolution. He was discharged a week after admission. Conclusions: diagnosis of spontaneous pneumomediastinum can be challenging in an emergency setting and having a variety of potentially life-threatening differential diagnoses. High suspicion levels will enable an adequate clinical and imaging assessment to confirm its diagnosis and avoid unnecessary invasive procedures.

Introdução: síndrome de Hammam é o aparecimento de pneumomediastino espontâneo associado ao enfisema, uma patologia rara na pediatria. Seus principais sintomas são dor aguda no peito, dispneia e enfisema subcutâneo. Objetivo: descrever um caso clínico com suspeita dessa síndrome por meio da análise do processo diagnóstico, estudos complementares e tratamento. Caso clínico: menino de 4 anos com histórico pessoal de laringite recorrente. Teve laringite aguda grave, o que exigiu ventilação não invasiva por 12 horas. Dentro de 24 horas após a internação, instalou-se abruptamente estridor inspirador, dificuldade respiratória, edema do pescoço e rosto com estalos ao nível do pescoço e face anterior do peito, estendido para ambos braços. Raios-x do tórax mostram enfisema subcutâneo extenso. Tomografia do pescoço e tórax exclui lesões nas vias aéreas. Com a sugestão da síndrome de Hammam em uma criança que apresentou como fator predisponente o episódio de laringite aguda, decidiu-se não continuar com estudos complementares. O tratamento fisiopatológico mostrou boa evolução clínica. A alta teve lugar dentro de uma semana da data da internação. Conclusões: o diagnóstico na urgência do pneumomediastino espontâneo pode representar um desafio, além do mais quando existem uma variedade de diagnósticos diferenciais que ameaçam a vida. A alta suspeita permitirá uma avaliação clínica e de imagem adequada para confirmar o diagnóstico e evitar procedimentos invasivos desnecessários.

Neumomediastino espontáneo de reentrada en la altitud: reporte de dos casos

Se describen dos casos de neumomediastino espontáneo (NME) en adolescentes varones, saludables y nativos de la altura cuando retornaron a sus hogares provenientes del nivel del mar. Ambos acudieron por el Servicio de Emergencia del hospital Víctor Ramos Guardia de Huaraz, Ancash (3052 m s. n. m.) en el mes de febrero del 2020. El primer caso es el de un joven de 16 años que retornó a su hogar (a 2964 m s. n. m.) luego de permanecer doce días a nivel del mar, en Lima. Seis horas después del regreso fue a trabajar a la chacra, se sintió cansado y empezó a toser, y luego empezó el dolor torácico, la disnea y el enfisema subcutáneo. El segundo caso corresponde a un varón de 17 años, que volvió a su hogar (3140 m s. n. m.) después de pasar dos semanas a nivel del mar (Barranca); doce horas después del retorno, va a trabajar a la chacra y presenta tos, disnea, dolor torácico, dolor de garganta y enfisema subcutáneo. Ambos jóvenes desarrollaron una hipoxemia. El neumomediastino espontáneo se diagnosticó con las radiografías de tórax. En el segundo paciente, el cuadro se asoció a un leve edema pulmonar de altura. Ninguno de los pacientes tenía antecedentes de traumatismos, uso de drogas ilícitas, comorbilidad o de enfermedades previas asociadas a la altura. El manejo de la enfermedad fue conservador, sintomático, de soporte y observación clínica. Cuando un paciente joven y saludable acude a la emergencia con dolor torácico, disnea y enfisema subcutáneo, el neumomediastino espontáneo se debe considerar como un posible diagnóstico y, de inmediato, solicitar radiografías torácicas, frontal y lateral, que abarquen la región cervical. El diagnóstico diferencial permite un manejo adecuado y preciso para los pacientes con neumomediastino espontáneo.

We describe two cases of spontaneous pneumomediastinum (SPM) that occurred in healthy, high-altitude native adolescent males when returning to their home from sea level. Both attended the Emergency Department of the Hospital Víctor Ramos Guardia in Huaraz, Ancash (3,052 m a.s.l.), in February 2020. Case 1 was a 16-year-old man who returned home (2,964 m a.s.l.) after twelve days at sea level (Lima). Six hours after returning, he went to work in the field. He then presented fatigue, cough, chest pain, dyspnea, and subcutaneous emphysema. Case 2 was a 17-year-old man who returned home (3,140 m a.s.l.) two weeks after staying at sea level (Barranca). Twelve hours after returning, he went to work in the field. He then presented cough, dyspnea, chest pain, sore throat, and subcutaneous emphysema. Both patients developed hypoxemia, and SPM was diagnosed with the help of chest X-rays. Case 2 was associated with mild high-altitude pulmonary edema. Both patients had no previous history of trauma, illicit drug use, comorbidity, and high-altitude-related diseases. Disease management was conservative, symptomatic, supportive, and based on clinical observation. When a healthy young patient comes to an emergency department because of chest pain, dyspnea, and subcutaneous emphysema, we should consider the possibility of SPM and immediately request frontal and lateral chest X-rays that include the cervical region. A differential diagnosis enables physicians to provide adequate and accurate treatment to patients with SPM.

Lesión laringotraqueal secundaria a traumatismo cerrado de cuello / Laryngotracheal injury secondary to blunt neck trauma

Resumen Los traumatismos contusos en la tráquea pueden provocar un compromiso agudo de las vías respiratorias, con implicaciones poten cialmente mortales. Representan el 5-10% de todos los casos traumatológicos, y se acompañan de una mortalidad de aproximadamente el 1-7%, siendo necesario su diagnóstico y manejo precoz. Los órganos frecuentemente lesionados son: estructuras vasculares, en un 20%, y se estima que el tracto aéreo y digestivo se encuentran comprometidos en un 10% de los casos.

Abstract Blunt trauma to the trachea can cause acute airway involvement, with life-threatening implications. They represent 5-10% of all trauma cases, and are accompanied by a mortality of approximately 1-7%, requiring early diagnosis and management. The organs frequently injured are: vascular structures, in 20%, and it is estimated that the air and digestive tracts are compromised in 10% of cases.

Neumomediastino espontáneo y dermatomiositis. Presentación de un caso / Spontaneous pneumomediastinum and dermatomyositis. A case report

RESUMEN La dermatomiositis forma parte de las miopatías inflamatorias idiopáticas. La presentación clínicamente amiopática comprende un grupo especial de pacientes, cuyo cuadro clínico está caracterizado por la presencia de lesiones cutáneas típicas, compromiso muscular mínimo o ausente y riesgo aumentado de enfermedad pulmonar intersticial. Se presenta el caso clínico de un paciente masculino de 47 años, con pérdida de peso marcada, debilidad muscular proximal discreta, malestar general, eritema en heliotropo, edema palpebral, torácico y disfagia funcional. Durante el ingreso se realizaron varios exámenes complementarios dentro de los que se incluyeron creatinphosphokinasa que fue normal, tomografía de tórax con presencia de fibrosis intersticial y biopsia de músculo compatible con los cambios de una miopatía inflamatoria idiopática. Durante su evolución desarrolló neumomediastino espontáneo. Como resultado de la investigación se diagnosticó dermatomiositis, con compromiso pulmonar. Por ser una entidad poco común y con una elevada mortalidad que solo disminuye si se instaura tratamiento inmunosupresor potente de forma temprana y porque en el caso que se presenta la enfermedad no había evolucionado según las formas clásicas descritas, de decidió su publicación. Actualmente el paciente se encuentra bajo tratamiento inmunosupresor y en evolución clínica.

ABSTRACT Dermatomyositis is one of the idiopathic inflammatory myopathies. The clinically amyopathic presentation comprises a special group of patients, whose clinical picture is characterized by the presence of typical skin lesions, minimal or absent muscle involvement, and an increased risk of interstitial lung disease. The clinical case of a 47-years-old male patient is presented, with marked weight loss, slight proximal muscle weakness, general discomfort, heliotrope erythema, eyelid and thoracic edema and functional dysphagia. During admission, several complementary tests were performed, including creatinphosphokinase, which was normal, a chest tomography with the presence of interstitial fibrosis, and a muscle biopsy compatible with the changes of an idiopathic inflammatory myopathy. During his evolution he developed spontaneous pneumomediastinum. As a result of the investigation, dermatomyositis was diagnosed, with pulmonary involvement. Because it is a rare entity with a high mortality that only decreases if powerful immunosuppressive treatment is started early and because in the case that the disease occurs it had not develop according to the classic forms described, it was decided to publish it. Currently the patient is under immunosuppressive treatment and in clinical evolution.

Enfisema subcutáneo relacionado con trauma facial en un adulto / Subcutaneous emphysema related to facial trauma in an adult

Se describe el caso clínico de un paciente de 45 años de edad, blanco, quien fue atendido en el cuerpo de guardia médica del Hospital Universitario Dr. Antonio Luaces Iraola, provincia de Ciego de Ávila, por presentar trauma facial, debido a caída por un resbalón y golpe en la cara con el borde de cemento de una piscina. Al realizar el examen físico se halló un enfisema cervicofacial. Se indicó tomografía axial computarizada, la cual mostró fractura de las paredes medial y lateral del seno maxilar izquierdo. Se decidió utilizar la técnica conservadora para extracción de aire mediante la colocación de agujas. El paciente evolucionó favorablemente y no tuvo recidivas.

The case report of a 45 years white patient is described who was assisted in the emergency department of Dr. Antonio Luaces Iraola University Hospital, Ciego de Ávila province, presenting a facial trauma, due to a fall by a slip and hit in the face with a swimming pool cement border. A cervicofacial emphysema was found when the physical exam was carried out. Computerized axial tomography was indicated, which showed fracture of the medial and lateral walls of the left maxillary sinus. It was decided to use the conservative technique for air extraction by means of the needles placement. The patient had a favorable clinical course and he didn't have relapses.

Primary repair: damage control surgery in esophageal trauma / El reparo primario: el control de daños en el trauma de esófago

Abstract Esophageal trauma is a rare but life-threatening event associated with high morbidity and mortality. An inadvertent esophageal perforation can rapidly contaminate the neck, mediastinum, pleural space, or abdominal cavity, resulting in sepsis or septic shock. Higher complications and mortality rates are commonly associated with adjacent organ injuries and/or delays in diagnosis or definitive management. This article aims to delineate the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia, on the surgical management of esophageal trauma following damage control principles. Esophageal injuries should always be suspected in thoracoabdominal or cervical trauma when the trajectory or mechanism suggests so. Hemodynamically stable patients should be radiologically evaluated before a surgical correction, ideally with computed tomography of the neck, chest, and abdomen. While hemodynamically unstable patients should be immediately transferred to the operating room for direct surgical control. A primary repair is the surgical management of choice in all esophageal injuries, along with endoscopic nasogastric tube placement and immediate postoperative care in the intensive care unit. We propose an easy-to-follow surgical management algorithm that sticks to the philosophy of "Less is Better" by avoiding esophagostomas.

Resumen El trauma esofágico es un evento poco frecuente pero potencialmente mortal. Una perforación esofágica inadvertida puede ocasionar la rápida contaminación del cuello, el mediastino, el espacio pleural o la cavidad abdominal, lo cual puede resultar en sepsis o choque séptico. Las complicaciones y la mortalidad aumentan con el retraso en el diagnóstico o manejo definitivo, y la presencia de lesiones asociadas. El objetivo del presente artículo es describir la experiencia adquirida por el grupo de cirugía de Trauma y Emergencias (CTE) de Cali, Colombia en el manejo del trauma de esófago de acuerdo con los principios de la cirugía de control de daños. Las lesiones esofágicas deben sospecharse en todo trauma toraco-abdominal o cervical en el que el mecanismo o la trayectoria de la lesión lo sugieran. El paciente hemodinámicamente estable se debe estudiar con imágenes diagnósticas antes de la corrección quirúrgica del defecto, idealmente por medio de tomografía computarizada del cuello, tórax y abdomen con contraste endovenoso. Mientras que en el paciente hemodinámicamente inestable se debe explorar y controlar la lesión. El reparo primario es el manejo quirúrgico de elección, con la previa colocación de una sonda nasogástrica y el seguimiento postoperatorio estricto en la unidad de cuidado intensivo. Se propone un algoritmo de manejo quirúrgico que resulta fácil de seguir y adopta la premisa "Menos es Mejor" evitando realizar derivaciones esofágicas.

Síndrome de Hamman: una causa rara de dolor torácico en niños / Hamman's syndrome: a rare cause of thoracic pain in children

Resumen Introducción: el dolor torácico es una causa frecuente de consulta al servicio de urgencias pediátricas. Una causa poco conocida es el neumomediastino, el cual puede clasificarse en secundario, cuando hay un desencadenante y en espontáneo, cuando no hay causa evidente. También es llamado síndrome de Hamman, el cual tiene una incidencia que oscila entre uno en 30 000 a 44 000 consultas a urgencias y se presenta predominantemente en hombres. Presentamos el caso de una niña de 12 años, previamente sana, quien consultó por un cuadro de 12 horas de evolución de dolor torácico de características pleuríticas, de inicio súbito, asociado a disnea y diaforesis, sin historia de trauma, síntomas respiratorios, gastrointestinales u otra sintomatología previa. Y a quien posteriormente se le hizo diagnóstico de neumomediastino espontáneo. Discusión: esta enfermedad es muy poco frecuente en niños. La mayoría de los casos se autolimitan rápidamente con manejo sintomático y muy pocos pueden complicarse con taponamiento cardiaco. La radiografía de tórax es el método diagnóstico más preciso.

Abstract Introduction: chest pain is a frequent cause of consultation to the pediatric emergency department. A little-known cause is pneumomediastinum, which can be classified as secondary, when there is a trigger and spontaneous, when there is no evident cause. It is also called Hamman's syndrome, which has an incidence ranging from one in 30 000 to 44 000 emergency department visits and occurs predominantly in males. We present the case of a 12-year-old girl, previously healthy, who consulted for 12 hours of chest pain with pleuritic characteristics of sudden onset, associated with dyspnea and diaphoresis, with no history of trauma, respiratory or gastrointestinal symptoms or other previous symptomatology. The patient was subsequently diagnosed with spontaneous pneumomediastinum. Discussion: this disease is very rare in children. Most cases are rapidly self-limited with symptomatic management and very few can be complicated with cardiac tamponade. Chest radiography is the most accurate diagnostic method.

Clinical characteristics and risk factors for mortality analysis of 94 cases of rheumatic diseases with pneumomediastinum / 中华风湿病学杂志

Objective:To analyze the clinical characteristics and risk factors of rheumatic diseases complicated with Pneumomediastinum (PnM).Methods:A retrospective analysis of 94 inpatients with rheumatic diseases associated PnM from Peking Union Medical College Hospital and Shanxi Bethune Hospital between January 1998 and October 2018 was carried out. Patients were divided into idiopathic inflammatory myopathies (IIM) and the non-IIM group. Clinical features, laboratory examinations and treatment were compared between the two groups. Cox proportional hazard model was used to investigate the risk factors for prognosis.Results:A total of 94 patients were included in the study, with an average age of (45±14) years. Forty-five (48%) of them were male. There were 62 patients in the IIM group and the other 32 were in the non-IIM group. Sixty-nine patients had predisposing factors before PnM. Severe cough and assisted mechanical ventilation were the most common causes. Compared with the non-IIM group, the incidence of digital vasculitis (29% vs 6%, χ2=6.540, P=0.008), arthritis (60% vs 28%, χ2=8.409, P=0.004), interstitial lung disease (ILD)(98% vs 78%, χ2=11.129, P=0.002) were higher in the IIM group, treatment with cyclophosphamide was higher in the IIM group ( χ2=4.458, P=0.035). There was non-significant difference in mortality between the two groups during hospitalization (50% vs 59%) and 6 months after PnM (64% vs72%) ( P>0.05). Pulmonary infection was the only risk factor for poor prognosis [ HR=3.131, 95% CI (1.025, 9.561), P=0.045], in which bacteria infection was the most common cause (65/75, 86.7%). Conclusion:PnM is a severe complication of rheumatic diseases. To get a good prognosis, rheumatol-ogists should balance the benefit and risk of infection of immunosuppressive therapy.

Pneumomediastinum and pneumopericardium in an adolescent with asthma attacks. case report

ABSTRACT Introduction: Pneumomediastinum is defined as the presence of air in the mediastinal cavity. This is a rare disease caused by surgical procedures, trauma or spontaneous scape of air from the lungs; asthma is a frequently associated factor. It has extensive differential diagnoses due to its symptoms and clinical signs. Case presentation: A 17-year-old female patient presented with respiratory symptoms for 2 days, dyspnea, chest pain radiated to the neck and shoulders, right supraclavicular subcutaneous emphysema, wheezing in both lung fields, tachycardia and tachypnea. On admission, laboratory tests revealed leukocytosis and neutrophilia, and chest X-ray showed subcutaneous emphysema in the right supraclavicular region. Diagnosis of pneumomediastinum was confirmed through a CT scan of the chest. The patient was admitted for treatment with satisfactory evolution. Discussion: Pneumomediastinum occurs mainly in young patients with asthma, and is associated with its exacerbation. This condition can cause other complications such as pneumopericardium, as in this case. The course of the disease is usually benign and has a good prognosis. Conclusion: Because of its presentation, pneumomediastinum requires clinical suspicion to guide the diagnosis and treatment. In this context, imaging is fundamental.

RESUMEN Introducción. El neumomediastino se define como la presencia de aire en la cavidad mediastinal; esta es una enfermedad poco frecuente que puede aparecer por procedimientos quirúrgicos, traumas o espontáneamente (siendo el asma es un factor frecuentemente asociado) y que tiene amplios diagnósticos diferenciales debido a su sintomatología y signos clínicos. Presentación del caso. Paciente femenina de 17 años de edad con síntomas respiratorios de 2 días de evolución que consistían en disnea, dolor torácico irradiado a cuello y hombros, enfisema subcutáneo supraclavicular derecho, sibilancias en ambos campos pulmonares, taquicardia y taquipnea. Al ingreso, los exámenes paraclínicos evidenciaron leucocitosis y neutrofilia, y la radiografía de tórax mostró enfisema subcutáneo en la región supraclavicular derecha. Se confirmó diagnóstico de neumomediastino con tomografía axial computarizada de tórax y se hospitalizó para manejo con evolución satisfactoria. Discusión. El neumomediastino se presenta principalmente en pacientes jóvenes con asma y está asociado a la exacerbación de esta, asimismo, puede generar otras complicaciones en sitios continuos, como el neumopericardio del presente caso. El curso de la enfermedad es usualmente benigno y de buen pronóstico. Conclusión. Por su presentación, el neumomediastino requiere una importante sospecha clínica para poder orientar su diagnóstico y tratamiento; por tanto, la imagenología es fundamental.

Enfisema sub-cutáneo en procedimientos de cirugía oral: Revisión de la literatura / Subcutaneous emphysema in oral surgery procedure: Review of literature

Objetivo: Determinar la causa más frecuente del enfisema sub-cutáneo en Cirugía oral, así como los factores de riesgo, diagnostico y tratamiento. Material y métodos: Búsqueda exhaustiva de la literatura a través de PubMed & Cochrane del 2009 al 2018. Se utilizaron los reportes sobre procedimientos quirúrgicos. Se excluyeron los casos ocasionados por trauma y tratamientos de conducto. Se encontró 21 reportes que cumplían con nuestros criterios de inclusión. Resultados: Se encontró que 14 de los 21 casos estaban relacionados con el uso de pieza de mano de alta velocidad. Otros casos incluyeron: 4 por el uso de la Jeringa Triple y 3 por actividades del paciente después del procedimiento quirúrgico. Conclusiones: El enfisema subcutáneo puede tener efectos graves y potencialmente mortales si no es tratado adecuadamente. Se debe tener un especial cuidado con el uso de piezas de mano de alta velocidad. Se deben dar indicaciones claras a los pacientes después de los procedimientos quirúrgicos.

Objective: Determine the most frequent cause of subcutaneous emphysema in oral surgery, as well as risk factors, diagnosis and treatment. Material and methods: Comprehensive literature search through PubMed & Cochrane from 2009 to 2018. Surgical procedures reports were used. Cases caused by trauma and root canals were excluded. We found 21 reports that met our inclusion criteria. Results: It was found that 14 of the 21 cases were related to the use of high-speed handpiece. Other cases included: 4 for the use of the Air Syringe and 3 for patient activities after the surgical procedure. Conclusions: Subcutaneous emphysema can have serious and life-threatening effects if not treated properly. Special care must be taken with the use of high-speed handpieces. Clear instructions should be given to patients after surgical procedures.

Clinical analysis of severe community-acquired pneumonia complicated with mediastinal emphysema after renal transplantation (report of 9 cases) / 器官移植

Objective To investigate the clinical treatment and outcomes of severe community-acquired pneumonia (CAP) complicated with mediastinal emphysema after renal transplantation. Methods Clinical data of9 patients with severe CAP complicated with mediastinal emphysema after renal transplantation were retrospectively analyzed. The acute physiology and chronic health evaluationⅡ(APACHEⅡ) and oxygenation index were recorded when the patients were admitted to the intensive care unit (ICU). The complications of mediastinal emphysema and corresponding treatment were observed. The treatment course during the ICU, mortality rate in ICU, ICU stay time and hospital stay time were recorded. All patients underwent pathogenic examinations. Results The APACHEⅡ score of9 patients with severe CAP complicated with mediastinal emphysema after renal transplantation was 14 (8-21) scores and the oxygenation index was 150 (133-189) mmHg. Among 9 patients, 3 cases were infected by bacteria alone, 3 cases were infected by bacterial infection combined with viral infection, 1 case was infected by mycobacterium tuberculosis complicated with other bacterial infection and 1 case was viral infection. No pathogenic evidence was detected in the remaining 1 patient. Mediastinal emphysema complicated with subcutaneous emphysema occurred in 7 cases and pneumothorax occurred in 6 cases. Treatment methods included anti-infection, modified immunosuppressive program, mediastinal drainage, thoracic closed drainage, subcutaneous incision and extracorporeal membrane oxygenation (ECMO) treatment. Six patients received invasive mechanical ventilation (IMV), 2 received non-invasive positive pressure ventilation (NIV) and 1 received high-flow nasal oxygen cannula (HFNC). Among 9 patients, the mortality rate in ICU was 6/9, the remaining 3 patients were recovered and discharged, the ICU stay time was 26 (17-40) d, and the total hospital stay time was 27-61 d. Conclusions Mediastinal emphysema is a serious complication of patients presenting with severe CAP after renal transplantation with a high mortality rate. For these patients, imaging evaluation, timely drainage and full sedation should be strengthened, and ECMO treatment should be delivered when necessary.

Pneumoparotitis

The objective is to review a case of pneumoparotitis and to discuss how knowledge of this unique presentation is important when making differential diagnoses in emergency medicine. A patient with recurrent subcutaneous emphysema of the head and neck is reviewed. Stenson's duct demonstrated purulent discharge. Physical examination revealed palpable crepitance of the head and neck. Fiberoptic laryngoscopy and barium esophagram were normal. Computed tomography demonstrated left pneumoparotitis and subcutaneous emphysema from the scalp to the clavicles. This is an unusual presentation of pneumoparotitis and malingering. Emergency physicians should be aware of pneumoparotitis and its presentation when creating a differential diagnosis for pneumomediastinum, which includes more life-threatening diagnoses such as airway or esophageal injuries.

Subcutaneous emphysema related to dental procedures

OBJECTIVES: The objective of this study was to analyze 11 cases of subcutaneous emphysema associated with dental procedures from a single hospital and discuss approaches for accurate diagnosis and treatment of the condition. MATERIALS AND METHODS: The medical records of 11 patients who were treated for subcutaneous emphysema related to dental procedures between January 2009 and April 2017 were analyzed retrospectively. Patients with subcutaneous emphysema within the facial area or that spread to the neck and beyond, including the facial region, were assigned to two groups and compared in terms of age, sex, and durations of antibiotic use, hospitalization, and follow-up until improvement. The correlation between location of the origin tooth and range of emphysema spread was analyzed. RESULTS: The average durations of antibiotic use during conservative treatment and follow-up until improvement were 8.55 days (standard deviation [SD], 4.46 days) and 1.82 weeks (SD, 1.19 weeks), respectively. There was no intergroup difference in duration of antibiotic use (P=0.329) or follow-up (P=0.931). Subcutaneous emphysema was more common after dental procedures involving the maxilla or posterior region than after those involving the mandible or anterior region. There was no significant difference in air distribution according to location of the air orifice (maxilla, mandible, or both; P=0.106). CONCLUSION: Upon adequate conservative treatment accompanied by prophylactic antibiotic treatment considering the risk of infection, patients showed signs of improvement within a few days or weeks. There was no significant difference in treatment period between patients with subcutaneous emphysema localized to the facial region and those with subcutaneous emphysema spreading to the neck or beyond. These findings need to be confirmed by analysis of additional cases.

Subcutaneous emphysema and pneumomediastinum during dental treatment

Subcutaneous emphysema is a rare complication of maxillofacial and dental surgery, and may be life-threatening because it can rapidly spread to the scalp, neck, and chest. We report a case of severe subcutaneous emphysema with pneumomediastinum during restorative dentistry in a child with difficulty in communication. The patient was hospitalized for conservative treatment and discharged after complete recovery as a result of timely diagnosis and treatment. Dentists and pediatricians should be aware of potential subcutaneous emphysema during dental treatment, with careful monitoring to ensure prompt diagnosis and treatment.

Spontaneous pneumomediastinum. case report

ABSTRACT Introduction: Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum. It is a rare entity considered benign and self-limiting, which mostly affects young adults. Its diagnosis is confirmed through clinical and radiological studies. Case description: 21-year-old male patient with cough and greenish expectoration for four days, associated with dyspnea, chest pain, fever and bilateral supraclavicular subcutaneous emphysema. Chest X-ray suggested pneumomediastinum, which was confirmed by tomography. The patient was hospitalized for observation and treatment. After a positive evolution, he was discharged on the sixth day. Discussion: SPM is a differential diagnosis in patients with chest pain and dyspnea. Its prevalence is lower than 0.01% and its mortality rate is low. It should be suspected in patients with chest pain and subcutaneous emphysema on physical examination. Between 70 and 90% of the cases can be identified by chest X-ray, while confirmation can be obtained through chest tomography. In most cases it does not require additional studies. Conclusion: SPM is a little known cause of acute chest pain, and rarely considered as a differential diagnosis; it is self-limited and has a good prognosis.

Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea / Massive subcutaneous emphysema, nemotórax voltage and pneumomediastinum after percutaneous tracheostomy

Mujer de 68 años que ingresa en la Unidad de Cuidados Intensivos por shock séptico. En el posoperatorio la paciente se mantiene inestable y se decide realizar traqueotomía percutánea (TP) por intubación prolongada. Al inicio la paciente presenta un enfisema subcutáneo que progresa hasta convertirse en masivo. Se realiza TC torácico donde se observa pérdida de la morfología habitual de la pared posterior traqueal con solución de continuidad. Tras revisión mediante traqueobroncoscopía se decide colocar cánula de traqueotomía larga para dejar la lesión proximal al neumotaponamiento y así evitar la fuga de aire. Desde la colocación de la nueva cánula, la paciente presenta una disminución progresiva del enfisema hasta su total resolución. La TP es un procedimiento seguro que se realiza con mucha frecuencia en los servicios de medicina intensiva, sin embargo, no está exenta de complicaciones. En la revisión de Powell y cols describen las complicaciones de la TP destacando la inserción peritraqueal, la hemorragia, las infecciones de la herida, el neumotórax y la muerte. El rango de complicaciones en la literatura oscila entre 3% y 18%. Además, no se encuentran diferencias significativas respecto a las complicaciones entre la TP y la técnica abierta.

A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.

Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years / Pneumomediastino espontâneo: experiência adquirida com 18 pacientes nos últimos 12 anos

ABSTRACT Objective: To characterize clinically all of the patients with spontaneous pneumomediastinum (SPM) admitted to an adult pulmonology ward in Lisbon, Portugal. Methods: This was a retrospective descriptive study of all adult patients (≥ 18 years of age) diagnosed with SPM between January of 2004 and September of 2015. Results: At least one predisposing factor was identified in most (88.9%) of the 18 patients who presented with SPM during the study period. With regard to precipitating factors, bouts of cough were present in 50.0% of the patients. Other precipitating factors included a sudden increase in tobacco consumption, inhaled drug use, occupational inhalation of varnish fumes, intense exercise, and vomiting. The most common complaints were dyspnea (in 83.3%) and chest pain (in 77.8%). Other complaints included cough, neck pain, dysphagia, and odynophagia. Subcutaneous emphysema was found in most of the patients. The diagnosis of SPM was based on chest X-ray findings in 61.1% of the patients. Conclusions: Although SPM is a rare condition, it should be considered in the differential diagnosis of chest pain and dyspnea. It can develop without a triggering event or conclusive findings on a chest X-ray, which is usually sufficient for diagnosis.

RESUMO Objetivo: Caracterizar clinicamente todos os pacientes com pneumomediastino espontâneo (PME) admitidos em uma enfermaria de pneumologia para adultos em Lisboa, Portugal. Métodos: Estudo descritivo retrospectivo no qual foram analisados todos os pacientes adultos (≥ 18 anos de idade) com diagnóstico de PME entre janeiro de 2004 e setembro de 2015. Resultados: Pelo menos um fator predisponente foi identificado na maioria (isto é, em 88,9%) dos 18 pacientes que apresentaram PME durante o período de estudo. No tocante a fatores precipitantes, crises de tosse ocorreram em 50,0% dos pacientes. Outros fatores precipitantes foram um aumento repentino do consumo de tabaco, uso de drogas inalatórias, inalação ocupacional de vapores de vernizes, exercício intenso e vômitos. As queixas mais comuns foram dispneia (em 83,3%) e dor torácica (em 77,8%). Outras queixas foram tosse, cervicalgia, disfagia e odinofagia. Constatou-se a presença de enfisema subcutâneo na maioria dos pacientes. O diagnóstico de PME baseou-se na radiografia de tórax em 61,1% dos pacientes. Conclusões: Embora seja uma doença rara, o PME deve ser levado em conta no diagnóstico diferencial de dor torácica e dispneia. O PME pode surgir sem um evento desencadeante e sem achados conclusivos na radiografia de tórax, que é geralmente suficiente para o diagnóstico.