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== Overview ==
== Overview ==
Pneumomediastinum can present with a various range of symptoms from sudden [[Chest pain|acute chest pain]], [[Dyspnea|shortness of breath]], [[cough]] to no symptoms at all. Diagnosis of pneumomediastinum depends on the associated or precipitating condition. On physical exam, pneumomediastinum is associated with a specific sign known as [[Hamman's sign]], which is the presence of mediastinal crunch or click present on [[auscultation]] over the [[Apex of the heart|cardiac apex]] and the [[left sternal border]] synchronous with the [[Heart sounds|heartbeat]]. Pneumomediastinum can routinely be diagnosed by [[chest X-ray]]. Diagnostic investigation of choice for pneumomediastinum is [[Computed tomography|CT-scan]] of the chest.


== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==


=== Study of choice ===
=== Study of choice ===
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
The diagnostic study of choice for pneumomediastinum is [[Computed tomography|CT-scan]] of the chest.<ref>{{cite book |title=Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA}}</ref><ref name="SandlerLlbshltz1975">{{cite journal|last1=Sandler|first1=Carl M.|last2=Llbshltz|first2=Herman I.|last3=Marks|first3=Gerald|last4=Libshitz|first4=Herman I.|title=Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction|journal=Radiology|volume=115|issue=3|year=1975|pages=539–540|issn=0033-8419|doi=10.1148/15.3.539}}</ref><ref name="KimYoo2016">{{cite journal|last1=Kim|first1=Hye Rin|last2=Yoo|first2=Seung Min|last3=Lee|first3=Hwa Yeon|last4=Han|first4=Jin Hee|last5=Frazier|first5=Aletta A|last6=White|first6=Charles S|title=Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum|journal=Acta Radiologica|volume=57|issue=12|year=2016|pages=1483–1489|issn=0284-1851|doi=10.1177/0284185116629830}}</ref><ref name="Moseley1960">{{cite journal|last1=Moseley|first1=John E.|title=Loculated Pneumomediastinum in the Newborn|journal=Radiology|volume=75|issue=5|year=1960|pages=788–790|issn=0033-8419|doi=10.1148/75.5.788}}</ref><ref name="pmid6725378">{{cite journal |vauthors=Hammond DI |title=The "ring-around-the-artery" sign in pneumomediastinum |journal=J Can Assoc Radiol |volume=35 |issue=1 |pages=88–9 |date=March 1984 |pmid=6725378 |doi= |url=}}</ref><ref name="Levin1973">{{cite journal|last1=Levin|first1=Bertram|title=The continuous diaphragm sign|journal=Clinical Radiology|volume=24|issue=3|year=1973|pages=337–338|issn=00099260|doi=10.1016/S0009-9260(73)80050-9}}</ref><ref name="LillardAllen1965">{{cite journal|last1=Lillard|first1=Richard L.|last2=Allen|first2=Parker|title=The Extrapleural Air Sign in Pneumomediastinum|journal=Radiology|volume=85|issue=6|year=1965|pages=1093–1098|issn=0033-8419|doi=10.1148/85.6.1093}}</ref>
 
OR
 
The following result of [gold standard test] is confirmatory of [disease name]:
* [Result 1]
* [Result 2]
 
OR
 
[Name of the investigation] must be performed when:
* The patient presents with [symptom/sign 1], [symptom/sign 2], and [symptom/sign 3].
* A [name of test] is positive for [sign 1], [sign 2], and [sign 3] in the patient.
 
OR
 
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
 
OR
 
The diagnostic study of choice for [disease name] is [name of the investigation].
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name].  
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
 
OR
 
[Disease name] is primarily diagnosed based on the clinical presentation.
 
OR
 
Investigations:
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
 
==== The comparison of various diagnostic studies for [disease name] ====
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background: #4479BA; color: #FFFFFF; text-align: center;" | Test
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|}
<small> [Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity</small>


===== Diagnostic results =====
===== Diagnostic results =====
The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:
The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum:
* [Finding 1]
*[[Subcutaneous emphysema]]
* [Finding 2]
*Naclerio V sign
**Seen in pneumomediastinum occurring often secondary to an [[Boerhaave syndrome|esophageal rupture]] but it is not entirely specific to that condition.
*[[Pneumopericardium]]
**Gas anterior to [[pericardium]]
*Ring around artery sign
**Gas around [[Pulmonary artery|pulmonary artery and main branches]]
*Tubular artery sign
**Gas outlining major [[Aorta|aortic branches]]
*Double bronchial wall sign
**Gas outlining [[Bronchus|bronchial wall]]
*Continuous [[Diaphragm (anatomy)|diaphragm]] sign
**Gas trapped posterior to [[pericardium]]
*Extrapleural sign
**Gas between [[parietal pleura]] and diaphragm
*Gas in [[pulmonary ligament]]
Pediatric pneumomediastinum has different appearances:
*Thymic wing sign
**Elevated [[thymus]]
*Haystack sign (the heart appears like a haystack in a Monet painting)
**Gas crossing the [[superior mediastinum]]


===== Sequence of Diagnostic Studies =====
===== Sequence of Diagnostic Studies =====
The [name of investigation] must be performed when:
Sequence of diagnostic studies:<ref name="pmid25774307">{{cite journal |vauthors=Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P |title=Pneumomediastinum |journal=J Thorac Dis |volume=7 |issue=Suppl 1 |pages=S44–9 |date=February 2015 |pmid=25774307 |pmc=4332083 |doi=10.3978/j.issn.2072-1439.2015.01.11 |url=}}</ref><ref name="pmid18721592">{{cite journal |vauthors=Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE |title=Spontaneous pneumomediastinum: a comparative study and review of the literature |journal=Ann. Thorac. Surg. |volume=86 |issue=3 |pages=962–6 |date=September 2008 |pmid=18721592 |doi=10.1016/j.athoracsur.2008.04.067 |url=}}</ref><ref name="pmid19748792">{{cite journal |vauthors=Perna V, Vilà E, Guelbenzu JJ, Amat I |title=Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients |journal=Eur J Cardiothorac Surg |volume=37 |issue=3 |pages=573–5 |date=March 2010 |pmid=19748792 |doi=10.1016/j.ejcts.2009.08.002 |url=}}</ref><ref name="pmid19411438">{{cite journal |vauthors=Iyer VN, Joshi AY, Ryu JH |title=Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients |journal=Mayo Clin. Proc. |volume=84 |issue=5 |pages=417–21 |date=May 2009 |pmid=19411438 |pmc=2676124 |doi=10.1016/S0025-6196(11)60560-0 |url=}}</ref>
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.


OR
{{Family tree/start}}
{{Family tree | | | | | | | | | | A01 | | | |A01= Symptomatic patient with the suspision of pneumomediastinum}}
{{Family tree | | | | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | | | | B01 | | | |B01= Chest X-ray}}
{{Family tree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | }}
{{Family tree | | | | C01 | | | | | | | | | | C02 |C01= Positive for pneumomediastinum| C02= Inconclusive}}
{{Family tree | |,|-|-|^|-|-|.| | | | | | | | |!| | | | | }}
{{Family tree | |!| | | | | |!| | | | | | | | |!| | | | | }}
{{Family tree | D01 | | | | D02 | | | | | | | D03 |D01= No Known causative factor identified| D02= Underlying pathological cause identified| D03=CT chest}}
{{Family tree | |!| | | | | |!| | | | | }}
{{Family tree | |!| | | | | |!| | | | | }}
{{Family tree | E01 | | | | E02 |E01= <br>•Observe patient in the hospital <br>•Discharge if symptoms resolve <br>•Follow up until complete resolutution of symptoms| E02= Treat underlying pathology}}
{{familytree/end}}


The various investigations must be performed in the following order:
==References==
* [Initial investigation]
{{Reflist|2}}
* [2nd investigation]


=== Name of Diagnostic Criteria ===
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Cardiology]]
[[Category:Medicine]]
[[Category:Surgery]]


'''It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.'''
[Disease name] is primarily diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
OR
There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
OR
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
[Disease name] may be diagnosed at any time if one or more of the following criteria are met:
* Criteria 1
* Criteria 2
* Criteria 3
OR
'''IF there are clear, established diagnostic criteria'''
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
'''IF there are no established diagnostic criteria'''
There are no established criteria for the diagnosis of [disease name].
==References==
{{Reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 15:12, 11 February 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2]

Overview

Pneumomediastinum can present with a various range of symptoms from sudden acute chest pain, shortness of breath, cough to no symptoms at all. Diagnosis of pneumomediastinum depends on the associated or precipitating condition. On physical exam, pneumomediastinum is associated with a specific sign known as Hamman's sign, which is the presence of mediastinal crunch or click present on auscultation over the cardiac apex and the left sternal border synchronous with the heartbeat. Pneumomediastinum can routinely be diagnosed by chest X-ray. Diagnostic investigation of choice for pneumomediastinum is CT-scan of the chest.

Diagnostic Study of Choice

Study of choice

The diagnostic study of choice for pneumomediastinum is CT-scan of the chest.[1][2][3][4][5][6][7]

Diagnostic results

The following finding(s) on performing CT-scan of the chest is confirmatory for pneumomediastinum:

Pediatric pneumomediastinum has different appearances:

  • Thymic wing sign
  • Haystack sign (the heart appears like a haystack in a Monet painting)
Sequence of Diagnostic Studies

Sequence of diagnostic studies:[8][9][10][11]

 
 
 
 
 
 
 
 
 
Symptomatic patient with the suspision of pneumomediastinum
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for pneumomediastinum
 
 
 
 
 
 
 
 
 
Inconclusive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Known causative factor identified
 
 
 
Underlying pathological cause identified
 
 
 
 
 
 
CT chest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

•Observe patient in the hospital
•Discharge if symptoms resolve
•Follow up until complete resolutution of symptoms
 
 
 
Treat underlying pathology

References

  1. ↑ Taveras, J., & Ferrucci, J. (1986). Radiology. Diagnosis/imaging/intervention. 5 volumes. Annual revision service. R. Health Professions,Philadelphia, PA.
  2. ↑ Sandler, Carl M.; Llbshltz, Herman I.; Marks, Gerald; Libshitz, Herman I. (1975). "Pneumoperitoneum, Pneumomediastinum and Pneumopericardium Following Dental Extraction". Radiology. 115 (3): 539–540. doi:10.1148/15.3.539. ISSN 0033-8419.
  3. ↑ Kim, Hye Rin; Yoo, Seung Min; Lee, Hwa Yeon; Han, Jin Hee; Frazier, Aletta A; White, Charles S (2016). "Presence of subpleural pulmonary interstitial emphysema as an indication of single or multiple alveolar ruptures on CT in patients with spontaneous pneumomediastinum". Acta Radiologica. 57 (12): 1483–1489. doi:10.1177/0284185116629830. ISSN 0284-1851.
  4. ↑ Moseley, John E. (1960). "Loculated Pneumomediastinum in the Newborn". Radiology. 75 (5): 788–790. doi:10.1148/75.5.788. ISSN 0033-8419.
  5. ↑ Hammond DI (March 1984). "The "ring-around-the-artery" sign in pneumomediastinum". J Can Assoc Radiol. 35 (1): 88–9. PMID 6725378.
  6. ↑ Levin, Bertram (1973). "The continuous diaphragm sign". Clinical Radiology. 24 (3): 337–338. doi:10.1016/S0009-9260(73)80050-9. ISSN 0009-9260.
  7. ↑ Lillard, Richard L.; Allen, Parker (1965). "The Extrapleural Air Sign in Pneumomediastinum". Radiology. 85 (6): 1093–1098. doi:10.1148/85.6.1093. ISSN 0033-8419.
  8. ↑ Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S, Kioumis I, Pitsiou G, Papaiwannou A, Karavergou A, Kipourou M, Lada M, Organtzis J, Katsikogiannis N, Tsakiridis K, Zarogoulidis K, Zarogoulidis P (February 2015). "Pneumomediastinum". J Thorac Dis. 7 (Suppl 1): S44–9. doi:10.3978/j.issn.2072-1439.2015.01.11. PMC 4332083. PMID 25774307.
  9. ↑ Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE (September 2008). "Spontaneous pneumomediastinum: a comparative study and review of the literature". Ann. Thorac. Surg. 86 (3): 962–6. doi:10.1016/j.athoracsur.2008.04.067. PMID 18721592.
  10. ↑ Perna V, Vilà E, Guelbenzu JJ, Amat I (March 2010). "Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients". Eur J Cardiothorac Surg. 37 (3): 573–5. doi:10.1016/j.ejcts.2009.08.002. PMID 19748792.
  11. ↑ Iyer VN, Joshi AY, Ryu JH (May 2009). "Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients". Mayo Clin. Proc. 84 (5): 417–21. doi:10.1016/S0025-6196(11)60560-0. PMC 2676124. PMID 19411438.

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