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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Sarcoidosis|'''Sarcoidosis''']] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Sarcoidosis|'''Sarcoidosis''']] | ||
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* African american race | * [[African american race]] | ||
* People of Scandinavian descent | * People of Scandinavian descent | ||
* Exposure to dusty/moldy environments | * Exposure to [[Dust|dusty]]/[[Mold|moldy]] environments | ||
* People between 25 and 40 years | * People between 25 and 40 years | ||
Genetic factors | [[Genetics|Genetic factors]] | ||
* The first-degree relatives have 55 fold increased the risk | * The first-degree relatives have 55 fold increased the risk | ||
* HLA-DRB1*1101 is associated with [[cardiac sarcoidosis]] and [[hypercalcemia]] | * [[HLA-DRB1|HLA-DRB1*1101]] is associated with [[cardiac sarcoidosis]] and [[hypercalcemia]] | ||
* Lofgren's | * [[Löfgren syndrome|Lofgren's syndrome]], [[HLA-DRB1|HLA-DRB1*03]] is 4 times higher | ||
* BTNL-2 (butyrophilin-like 2) gene | * [[BTNL2|BTNL-2 (butyrophilin-like 2)]] gene | ||
Immune System | Immune System | ||
* Higher expression of [[serum amyloid A]] | * Higher expression of [[serum amyloid A]] | ||
Line 796: | Line 796: | ||
* [[Etanercept]] | * [[Etanercept]] | ||
* Ipilimumab | * [[Ipilimumab]] | ||
* [[Infliximab]] | * [[Infliximab]] | ||
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Line 805: | Line 805: | ||
* [[fever]] | * [[fever]] | ||
* [[weight loss]]. | * [[weight loss]]. | ||
Cutaneous [[sarcoidosis]] | |||
* [[Papule|Papular]], [[Nodular lesions|nodular]], [[Plaque|plaque-like]], [[lupus pernio]], [[erythema nodosum]], [[Subcutaneous tissue|subcutaneous]] [[sarcoidosis]] | |||
Ocular [[sarcoidosis]] | |||
Ocular | |||
* [[dry eye]], [[blurred vision]], [[photophobia]], [[red eye]], [[Eye pain|pain]] | * [[dry eye]], [[blurred vision]], [[photophobia]], [[red eye]], [[Eye pain|pain]] | ||
* Intraocular sarcoidosis | * Intraocular [[sarcoidosis]] | ||
** Anterior, intermediate, and posterior [[uveitis]] | ** Anterior, intermediate, and posterior [[uveitis]] | ||
* Extraocular orbital sarcoidosis | * Extraocular orbital [[sarcoidosis]] | ||
** Involvement of [[Lacrimal gland|lacrimal glands]], [[conjunctiva]], [[extraocular muscles]], [[Optic nerve|optic nerve,]] and a | ** Involvement of [[Lacrimal gland|lacrimal glands]], [[conjunctiva]], [[extraocular muscles]], [[Optic nerve|optic nerve,]] and a mass | ||
Upper | [[Upper respiratory tract]] | ||
* Cough | * [[Cough]] | ||
* Nasal congestion | * [[Nasal congestion]] | ||
* Nasal crusting | * Nasal crusting | ||
* [[anosmia]] | * [[anosmia]] | ||
* [[epistaxis]] | * [[epistaxis]] | ||
* Nasal polyposis | * [[Nasal polyp|Nasal polyposis]] | ||
Cardiac | [[Sarcoidosis|Cardiac sarcoidosis]] | ||
* [[Palpitation|Palpitations]] | * [[Palpitation|Palpitations]] | ||
* [[syncope]] | * [[syncope]] | ||
Line 829: | Line 828: | ||
* [[chest pain]] | * [[chest pain]] | ||
* [[sudden cardiac death]] ([[SCD]]) | * [[sudden cardiac death]] ([[SCD]]) | ||
Neurosarcoidosis | [[Neurosarcoidosis]] | ||
* | * [[facial nerve palsy|Peripheral facial nerve palsy]] | ||
* [[Polyuria]] | * [[Polyuria]] - [[polydipsia]] | ||
* Disturbance in body temperature and [[libido]] due to hypothalamic inflammation | * Disturbance in body temperature and [[libido]] due to [[hypothalamic inflammation]] | ||
* Seizures | * [[Seizure|Seizures]] | ||
* Impairment in sleep | * [[Sleep disturbance|Impairment in sleep]] | ||
Reticuloendothelial | [[Reticuloendothelial system]] | ||
* Neck or axillary mass | * [[Neck masses|Neck]] or [[Axillary lymph nodes|axillary mass]] | ||
* Lymphadenopathy | * [[Lymphadenopathy]] | ||
* Hepatosplenomegaly | * [[Hepatosplenomegaly]] | ||
Musculocutaneous | [[Musculocutaneous]] | ||
* Acute sarcoid arthritis or acute polyarthritis | * Acute [[sarcoid arthritis]] or [[Polyarthritis|acute polyarthritis]] | ||
* Chronic arthritis | * [[Arthritis|Chronic arthritis]] | ||
* [[Myopathy]](diffuse granulomatous myositis) | * [[Myopathy]](diffuse granulomatous myositis) | ||
Lofgren | [[Löfgren syndrome|Lofgren syndrome]] | ||
* [[erythema nodosum]] | * [[erythema nodosum]] | ||
* [[hilar lymphadenopathy]] | * [[hilar lymphadenopathy]] | ||
* Migratory polyarthralgia | * [[Migratory polyarthralgia]] | ||
* [[fever]] | * [[fever]] | ||
Exocrine | [[Exocrine gland|Exocrine glands]] | ||
* Painless swelling of [[salivary glands]] and [[parotid]] | * Painless [[Swelling (medical)|swelling]] of [[salivary glands]] and [[parotid gland]] | ||
* [[Sicca syndrome]] and [[xerostomia]] | * [[Sicca syndrome]] and [[xerostomia]] | ||
Renal & | Renal & electrolyte | ||
* Renal colic caused by [[nephrolithiasis]] | * [[Renal colic]] caused by [[nephrolithiasis]] | ||
* Uremia due to [[interstitial nephritis]] | * [[Uremia, acute|Uremia]] due to [[interstitial nephritis]] | ||
* | * | ||
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Revision as of 16:49, 11 February 2019
piIEditor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Trusha Tank, M.D.[3]
Overview
Differential diagnosis of mediastinal mass
Wide variety of medical conditions can present as a mediastinal mass on radiological imaging.
- Mediastinal mass may cause obstruction, entrapment or infiltration of other mediastinal organs such as: Trachea, bronchi, esophagus, aorta, superior vena cava (SVC) or heart.[1]
- Disorder caused by any kind of mediastinal mass is collectively known as: Mediastinal syndromes
- Mediastinal syndrome includes:
- Compression of the trachea: Dyspnea and respiratory insufficiency.
- Compression of the esophagus: Dysphagia.
- Compression of SVC causes superior vena cava syndrome: Vein distention, edema of the face or upper extremities and a positive Pemberton's sign.
- Pemberton's sign: Development of suffusion, plethora, or duskiness upon elevation of the arms above the head in patient
- Superior vena cava syndrome is the most severe complication of mediastinal syndrome and a medical emergency.
ABBREVIATIONS: N/A: Not available, SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease, T3: Triiodothyronine, T4: Thyroxine, TSH: Thyroid stimulating hormone, TFT: Thyroid function test | |||||||||
Class | Disease | Etiology | Clinical presentation | Paraclinical findings | |||||
---|---|---|---|---|---|---|---|---|---|
General symptoms | Mediastinal syndrome | ||||||||
Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings | ||||
Anterior mediastinal mass | |||||||||
Tumors | Thymoma |
|
+ | + | + | Biopsy:
|
Associated condition
| ||
Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings | |
Fatty mass |
|
|
- | - | - | MRI:
|
Fatty mass can be:
| ||
Non-Hodgkin lymphoma |
(HIV, Hep C, HTLV-1, EBV, HHV-8, H. pylori, psittacosis, Campylobacter jejuni)
(pesticides, methotrexate, TNF inhibitors, trichloroethylene)
|
|
+/- | +/- | +/- | Excisional lymph node biopsy with immunohistochemical study
|
| ||
Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings | |
Teratoma |
|
Benign
Malignant |
+/- | +/- | +/- | Chest CT scan:
|
N/A | ||
Thyroid disease | Thyroid cancer |
|
|
+ | + | - | US guided biopsy: | TFT | |
Goiter |
|
+ | + | - | Radioactive iodine scan:
|
Hyperavtive gland (hyperthyroid):
Hypoactive gland (hypothyroid):
Normal functioning gland (euthyroid):
| |||
Class | Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings |
Middle mediastinal mass | |||||||||
CVS disease | Pericardial effusion |
|
|
+ | +/- | - | Echocardiography guided pericardiocentesis:
|
Physical findings:
EKG: Echo:
| |
Aortic dissection |
|
+ | +/- | + | MRI: | TEE:
CTA:
| |||
Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings | |
Superior vena cava obstruction | Compression of SVC from: |
|
+ | + | ++ | Contrast-enhanced CT scan:
|
Invasive contrast venography:
| ||
Partial anomalous pulmonary venous connection |
|
|
+ | - | - | MRI with contrast:
|
Associated with
PFT:
| ||
GI disease | Esophageal achalasia |
|
+ | + | - | High resolution manometry (HRM):
|
X ray:
| ||
Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings | |
Esophageal cancer |
|
|
- | + | - | Endoscopy with biopsy:
|
Barium swallow:
| ||
Esophageal rupture |
|
Other: Patients with cervical perforations can present with
|
+ | + | - | Esophagogram:
|
CT scan:
| ||
Hiatus hernia |
|
- | + | - | High resolution manometry with esophageal pressure topography (EPT):
|
Ultrasound:
Ultrasound in pediatric population:
| |||
Class | Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings |
Pulmonary disease | Hilar lymphadenopathy | Lymphadenopathy:
|
Constituitional symptoms like:
|
+ | - | - | Lymph node biopsy and histopathology | CT scan | |
Pneumomediastinum |
|
|
CT scan:
Pediatric pneumomediastinum: |
Physical exam:
| |||||
Sarcoidosis |
Immune System
Drug side effect |
Cutaneous sarcoidosis Ocular sarcoidosis
Renal & electrolyte
|
+ | Endoscopy with biopsy and histopathology | |||||
Mediastinal tumor | Mediastinal tumor | ||||||||
Mediastinal germ cell tumor | |||||||||
Infection | Mediastinitis | ||||||||
Anthrax | |||||||||
Tularemia | |||||||||
Cystic disease | Dermoid cyst | ||||||||
Bronchogenic cyst | |||||||||
Chronic
inflammatory |
Churg-Strauss syndrome | ||||||||
Class | Disease | Etiology | Symptoms | Dyspnea/
RI |
Dysphagia | SVCS | Gold standard | Image | Additional findings |
Posterior mediastinal mass | |||||||||
CNS disease | Meningocele[2] | ||||||||
Neurilemmoma[2] | |||||||||
ABBREVIATIONS: N/A: Not available, SOB: Shortness of breath, M/C: Most common, RI: Respiratory insufficiency, NM: Neuromuscular system, SVCS: Superior vena cava syndrome, SLE: Systemic lupus erythematosus disease, T3: Triiodothyronine, T4: Thyroxine, TSH: Thyroid stimulating hormone, TFT: Thyroid function test |
- Superior vena cava obstruction
- Partial anomalous pulmonary venous connection
- Esophageal achalasia
- Esophageal cancer
- Esophageal rupture
- Hiatus hernia
- Hilar lymphadenopathy
- Pneumomediastinum
- Sarcoidosis
- Lymphoma
- Neurilemmoma
- Non-Hodgkin lymphoma
- Teratoma
- Thymoma
References
- ↑ Zardi EM, Pipita ME, Afeltra A (October 2016). "Mediastinal syndrome: A report of three cases". Exp Ther Med. 12 (4): 2237–2240. doi:10.3892/etm.2016.3596. PMC 5038184. PMID 27698718.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Juanpere S, Cañete N, Ortuño P, Martínez S, Sanchez G, Bernado L (February 2013). "A diagnostic approach to the mediastinal masses". Insights Imaging. 4 (1): 29–52. doi:10.1007/s13244-012-0201-0. PMID 23225215.
- ↑ Molinari F, Bankier AA, Eisenberg RL (November 2011). "Fat-containing lesions in adult thoracic imaging". AJR Am J Roentgenol. 197 (5): W795–813. doi:10.2214/AJR.11.6932. PMID 22021525.
- ↑ Sandlund JT (2015). "Non-Hodgkin Lymphoma in Children". Curr Hematol Malig Rep. 10 (3): 237–43. doi:10.1007/s11899-015-0277-y. PMID 26174528.
- ↑ Armitage JO, Gascoyne RD, Lunning MA, Cavalli F (2017). "Non-Hodgkin lymphoma". Lancet. 390 (10091): 298–310. doi:10.1016/S0140-6736(16)32407-2. PMID 28153383.
- ↑ Yalagachin GH (June 2013). "Anterior mediastinal teratoma- a case report with review of literature". Indian J Surg. 75 (Suppl 1): 182–4. doi:10.1007/s12262-012-0569-6. PMID 24426558.
- ↑ No TH, Seol SH, Seo GW, Kim DI, Yang SY, Jeong CH, Hwang YH, Kim JY (September 2015). "Benign Mature Teratoma in Anterior Mediastinum". J Clin Med Res. 7 (9): 726–8. doi:10.14740/jocmr2270w. PMC 4522994. PMID 26251691.
- ↑ "Benign thyroid enlargement (non-toxic multinodular goiter): Overview".
- ↑ Vanneman MW, Fikry K, Quraishi SA, Schoenfeld W (August 2015). "A Young Man with a Mediastinal Mass and Sudden Cardiac Arrest". Ann Am Thorac Soc. 12 (8): 1235–9. doi:10.1513/AnnalsATS.201504-212CC. PMID 26317273.
- ↑ Salem K, Mulji A, Lonn E (November 1999). "Echocardiographically guided pericardiocentesis - the gold standard for the management of pericardial effusion and cardiac tamponade". Can J Cardiol. 15 (11): 1251–5. PMID 10579740.
- ↑ Weissmann-Brenner A, Schoen R, Divon MY (2004). "Aortic dissection in pregnancy". Obstet Gynecol. 103 (5 Pt 2): 1110–3. doi:10.1097/01.AOG.0000124984.82336.43. PMID 15121626.
- ↑ Brooke V, Goswami S, Mohanty A, Kasi PM (2012). "Aortic dissection and renal failure in a patient with severe hypothyroidism". Case Rep Med. 2012: 842562. doi:10.1155/2012/842562. PMC 3399550. PMID 22829842.
- ↑ "Classification of diabetic retinopathy from fluorescein angiograms. ETDRS report number 11. Early Treatment Diabetic Retinopathy Study Research Group". Ophthalmology. 98 (5 Suppl): 807–22. 1991. PMID 2062514.
- ↑ Uberoi R (2006). "Quality assurance guidelines for superior vena cava stenting in malignant disease". Cardiovasc Intervent Radiol. 29 (3): 319–22. doi:10.1007/s00270-005-0284-9. PMID 16502166.
- ↑ Cohen R, Mena D, Carbajal-Mendoza R, Matos N, Karki N (2008). "Superior vena cava syndrome: A medical emergency?". Int. J. Angiol. 17 (1): 43–6. PMID 22477372.
- ↑ Sears EH, Aliotta JM, Klinger JR (2012). "Partial anomalous pulmonary venous return presenting with adult-onset pulmonary hypertension". Pulm Circ. 2 (2): 250–5. doi:10.4103/2045-8932.97637. PMC 3401879. PMID 22837866.
- ↑ Broy C, Bennett S (June 2008). "Partial anomalous pulmonary venous return". Mil Med. 173 (6): 523–4. PMID 18595412.
- ↑ Gockel I, Müller M, Schumacher J (2012). "Achalasia--a disease of unknown cause that is often diagnosed too late". Dtsch Arztebl Int. 109 (12): 209–14. doi:10.3238/arztebl.2012.0209. PMC 3329145. PMID 22532812.
- ↑ Ghoshal UC, Daschakraborty SB, Singh R (2012). "Pathogenesis of achalasia cardia". World J. Gastroenterol. 18 (24): 3050–7. doi:10.3748/wjg.v18.i24.3050. PMC 3386318. PMID 22791940.
- ↑ Ates F, Vaezi MF (2015). "The Pathogenesis and Management of Achalasia: Current Status and Future Directions". Gut Liver. 9 (4): 449–63. doi:10.5009/gnl14446. PMC 4477988. PMID 26087861.
- ↑ Boeckxstaens GE, Zaninotto G, Richter JE (2013). "Achalasia". Lancet. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
- ↑ Corley DA, Kerlikowske K, Verma R, Buffler P. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. Gastroenterology 2003;124:47-56. PMID 12512029. See also NCI - "Esophageal Cancer (PDQ®): Prevention".
- ↑ Wong A, Fitzgerald RC. Epidemiologic risk factors for Barrett's esophagus and associated adenocarcinoma. Clin Gastroenterol Hepatol. 2005 Jan;3(1):1-10. PMID 15645398
- ↑ Ye W, Held M, Lagergren J, Engstrand L, Blot WJ, McLaughlin JK, Nyren O. Helicobacter pylori infection and gastric atrophy: risk of adenocarcinoma and squamous-cell carcinoma of the esophagus and adenocarcinoma of the gastric cardia. J Natl Cancer Inst. 2004 Mar 3;96(5):388-96. PMID 14996860
- ↑ Nakajima S, Hattori T. Oesophageal adenocarcinoma or gastric cancer with or without eradication of Helicobacter pylori infection in chronic atrophic gastritis patients: a hypothetical opinion from a systematic review. Aliment Pharmacol Ther. 2004 Jul;20 Suppl 1:54-61. PMID 15298606
- ↑ NCI Prevention: Dietary Factors, based on Chainani-Wu N. Diet and oral, pharyngeal, and esophageal cancer. Nutr Cancer 2002;44:104-26. PMID 12734057.
- ↑ McGovern M, Egerton MJ (1991). "Spontaneous perforation of the cervical oesophagus". Med. J. Aust. 154 (4): 277–8. PMID 1994204.
- ↑ Wilson RF, Sarver EJ, Arbulu A, Sukhnandan R (1971). "Spontaneous perforation of the esophagus". Ann. Thorac. Surg. 12 (3): 291–6. PMID 5112482.
- ↑ Bladergroen MR, Lowe JE, Postlethwait RW (1986). "Diagnosis and recommended management of esophageal perforation and rupture". Ann. Thorac. Surg. 42 (3): 235–9. PMID 3753071.
- ↑ Dodds WJ, Stewart ET, Vlymen WJ (1982). "Appropriate contrast media for evaluation of esophageal disruption". Radiology. 144 (2): 439–41. doi:10.1148/radiology.144.2.7089304. PMID 7089304.
- ↑ James AE, Montali RJ, Chaffee V, Strecker EP, Vessal K (1975). "Barium or gastrografin: which contrast media for diagnosis of esophageal tears?". Gastroenterology. 68 (5 Pt 1): 1103–13. PMID 1126592.
- ↑ Schwartz SS (1975). "Letter: Barium or gastrografin: which contrast media for diagnosis of esophageal tears?". Gastroenterology. 69 (6): 1377. PMID 1193339.
- ↑ Vessal K, Montali RJ, Larson SM, Chaffee V, James AE (1975). "Evaluation of barium and gastrografin as contrast media for the diagnosis of esophageal ruptures or perforations". Am J Roentgenol Radium Ther Nucl Med. 123 (2): 307–19. PMID 1115308.
- ↑ Khajanchee YS, Cassera MA, Swanström LL, Dunst CM (January 2013). "Diagnosis of Type-I hiatal hernia: a comparison of high-resolution manometry and endoscopy". Dis. Esophagus. 26 (1): 1–6. doi:10.1111/j.1442-2050.2011.01314.x. PMID 22320417.
- ↑ Chang P, Friedenberg F (2014). "Obesity and GERD". Gastroenterol Clin North Am. 43 (1): 161–73. doi:10.1016/j.gtc.2013.11.009. PMC 3920303. PMID 24503366.
- ↑ Jash, Debraj; Maji, Arnab; Patra, Anupam; Sarkar, Supriya (2013). "Approach to unequal hilum on chest X-ray". The Journal of Association of Chest Physicians. 1 (2): 32. doi:10.4103/2320-8775.123204. ISSN 2320-8775.
- ↑ Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A (2014). "Peripheral lymphadenopathy: approach and diagnostic tools". Iran J Med Sci. 39 (2 Suppl): 158–70. PMC 3993046. PMID 24753638.
- ↑ Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A (2014). "Peripheral lymphadenopathy: approach and diagnostic tools". Iran J Med Sci. 39 (2 Suppl): 158–70. PMC 3993046. PMID 24753638.
- ↑ Lymph node enlargment. Radiopedia. http://radiopaedia.org/articles/lymph-node-enlargement Accessed on May 9, 2016
- ↑ Utsumi T, Shiono H, Fukai I, Akashi A (2007). "Artificial pneumomediastinum facilitates thoracoscopic surgery in anterior mediastinum". Interactive cardiovascular and thoracic surgery. 6 (3): 411–2. doi:10.1510/icvts.2006.147355. PMID 17669882.
- ↑ name="pmid18721592">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.
- ↑ 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.
- ↑ . doi:10.3978/j.issn.2072-1439.2015.01.11. Missing or empty
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(help) - ↑ Chiu CY, Wong KS, Yao TC, Huang JL (March 2005). "Asthmatic versus non-asthmatic spontaneous pneumomediastinum in children". Asian Pac. J. Allergy Immunol. 23 (1): 19–22. PMID 15997870.
- ↑ 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.
- ↑ Dionísio, Patrícia; Martins, Luís; Moreira, Susana; Manique, Alda; Macedo, Rita; Caeiro, Fátima; Boal, Luísa; Bárbara, Cristina (2017). "Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years". Jornal Brasileiro de Pneumologia. 43 (2): 101–105. doi:10.1590/s1806-37562016000000052. ISSN 1806-3756.