Working Diagnosis:
Spontaneous Pneumomediastinum (SPM) due to exertion

Treatment:
The patient was admitted to the hospital, given a dose of empiric Unasyn, started on IV fluids and kept NPO. He remained stable throughout hospitalization. He was slowly advanced to regular PO intake and was able to be discharged approximately 24 hours after admission.

Outcome:
On follow up, he continued to feel well with no residual odynophagia, and was tolerating a regular diet without difficulty. He was advanced back to light physical activity including light catch, swinging, and stationary biking. He followed up with CT surgery 10 days after discharge, with X-ray showing no residual pneumomediastinum. He was cleared for advancement to full baseball participation.

Author's Comments:
SPM is typically caused by air leaking through small alveolar ruptures, and less commonly caused by air escaping from the upper respiratory tract or GI tract. The most common predisposing condition is asthma. However, rarely an intense Valsalva maneuver or a blow to the chest wall can cause this, which is the case in intense sporting activities. The most common presenting features of SPM include chest pain, dyspnea, cough, neck pain, odynophagia and dysphagia. Physical exam can show subcutaneous crepitus on neck/chest palpation or Hamman sign on cardiac auscultation. The diagnosis is confirmed with frontal and lateral chest radiographs which show lucent streaks of gas in the mediastinum.

Editor's Comments:
Spontaneous Pneumomediastinum (SPM) is rare condition. While asthma is the most common predisposing condition, coughing, vomiting, and drug use can also lead to SPM. It is important to ask about drug use on history when evaluating an athlete.

Some diagnoses that need to be ruled out when elevating an athlete for SPM are cardiac tamponade, dissecting aortic aneurysm, and esophageal rupture.

Chest X-ray or CT scan are considered the diagnostic tests of choice.

Treatment is usually conservative with rest, oxygen, and pain management. However, patients diagnosed with SPM need to be monitored carefully as pneumothorax or pneumopericardium can be rare complications of SPM.

References:
Sports-related spontaneous pneumomediastinum. Mihos, Petros et al. The Annals of Thoracic Surgery, Volume 78, Issue 3, 983-986.

Morgan, CT, Maloney, JD, Decamp, MM, McCarthy, DP. A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem. J Thorac Dis. 2021 June; 13(6): 3721-3730. doi: 10.21037/jtd-21-193. PMID: 34277063; PMCID: PMC8264673.

Vanzo, Valentina et al. "Pneumomediastinum and Pneumopericardium in an 11-Year Old Rugby Player: A Case Report." Journal of Athletic Training. 48.2 (2013): 277-281. Web.

Sahni, Sonu et al. "Spontaneous Pneumomediastinum: Time for Consensus." North American Journal of Medical Sciences. 5.8 (2013): 460-464. Web.

Takada, Kazuto et al. "Management of Spontaneous Pneumonimediastinum Based on Clinical Experience of 25 Cases." Respiratory Medicine. 102.9 (2008): 1329-1334. Web.

Gerazounis, Michalis et al. "Spontaneous Pneumomediastinum: A Rare Benigh Entity." The Journal of Thoracic and Cardiovascular Surgery. 126.3 (2003): 774-776. Web.

Chalumeau, M et al. "Spontaneous Pneumomediastinum in Children." Pediatric Pulmonology. 31.1 (2001): 67-75. Web.

Return To The Case Studies List.