Pneumomediastinum usually occurs following an airleak from the lungs, or from a perforated oesophagus. We report on a 30-year-old man who developed pneumomediastinum after scuba diving. The patient presented with acute onset of throat pain, odynophagia, and hoarseness of voice. The literature is reviewed for this condition.published_or_final_versio

Cheung, HYS

Kwok, KF

Law, S

Wong, J

Wong, KH

Hong Kong Medical Journal

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Title Spontaneous pneumomediastinum in a scuba diverAuthor(s) Cheung, HYS; Law, S; Wong, KH; Kwok, KF; Wong, JCitation Hong Kong Medical Journal, 2006, v. 12 n. 2, p. 152-153Issued Date 2006URL http://hdl.handle.net/10722/45387Rights Creative Commons: Attribution 3.0 Hong Kong License152      Hong Kong Med J Vol 12 No 2 April 2006CASE REPORTKey words:Diving;Pneumomediastinum, diagnostic;Radiography, thoracic;Sports medicine !  !"#$%& !"# !Hong Kong Med J 2006;12:152-3Spontaneous pneumomediastinum in ascuba diver○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ !" #$%&'()*+,-./Division of Esophageal Surgery,Department of Surgery, University ofHong Kong, Queen Mary Hospital,Pokfulam Road, Hong KongHYS Cheung, MB, ChB, MRCSS Law, MS, FRCS (Edin)KH Wong, MB, BS, FRCS (Edin)KF Kwok, MB, BS, FRCS (Edin)J Wong, PhD, FRACSCorrespondence to: Prof S Law(e-mail: slaw@hku.hk)HYS Cheung  S Law  KH Wong  KF Kwok  J Wong  Pneumomediastinum usually occurs following an airleak from the lungs,or from a perforated oesophagus. We report on a 30-year-old man whodeveloped pneumomediastinum after scuba diving. The patient presentedwith acute onset of throat pain, odynophagia, and hoarseness of voice. Theliterature is reviewed for this condition. !"#$% &'()*+,-./0123456789:;<=>?@ !"#$%&'()*+,-./%&01234567489:;<+ !"#$%&'()*+IntroductionPneumomediastinum usually occurs as a result of a pulmonary airleak that isinduced by a variety of conditions. One important differential diagnosis isperforated oesophagus. We report on a patient who presented with pneumo-mediastinum after scuba diving.Case reportIn August 2004, a healthy 30-year-old man who was a professional scuba diverpresented with acute onset of throat pain after diving to a depth of around40 feet. He also complained of odynophagia and hoarseness of voice. He had nofever, chest pain, or dyspnoea and his pulse rate was 69 beats per min and bloodpressure was 154/81 mm Hg. Subcutaneous emphysema was detected in his rightneck and upper chest wall. Air entry to both lungs was equal and satisfactory.Laboratory analyses showed mildly elevated white cell count (11.6 x 109 /L,with neutrophil predominance, 7.9 x 109 /L) and normal liver and renal functions.Lateral neck radiograph revealed an abnormal gas shadow in theretropharyngeal area and subcutaneous emphysema. Chest X-ray revealedpneumomediastinum without evidence of pneumothorax. This was confirmedon computed tomographic scan (Fig). A subsequent contrast swallow studyruled out oesophageal perforation. The patient was treated conservatively andwas discharged on the third day after radiograph confirmed complete resolutionof the pneumomediastinum.DiscussionSpontaneous pneumomediastinum, first reported by Hamman in 1939,1 is anuncommon self-limiting condition that predominantly affects young, tall, thin,and healthy men in the second to fourth decades of life and, occasionally,pregnant women. It has been reported in patients undergoing mechanicalventilation, following ecstasy abuse, women in labour, hyperemesis gravidarum,diabetic ketoacidosis. Occurrence has also been linked with underlyingpulmonary conditions such as asthma, idiopathic pulmonary fibrosis, severeacute respiratory syndrome, and with sporting activities such as weightlifting,2football,3 basketball, and volleyball.4Diving-related diseases include decompression sickness, baro-sinusitis,perforated tympanic membrane, temporo-mandibular joint dysfunction, arterialHong Kong Med J Vol 12 No 2 April 2006      153Pneumomediastinum in a scuba divergas embolism, and hyperbaric-triggered migraine.5 Up to2.3% of experienced divers have been reported to developpermanent disabilities such as balance disorders, hearingloss, and tinnitus.6 Pulmonary airleaks may result frompulmonary barotrauma sustained during scuba or com-pressed air diving, with rupture of the terminal alveolisecondary to increased intrathoracic pressure. Air tracksalong the peri-bronchial vascular sheaths towards thehilum of the lung and spreads through the tissue plane,causing subcutaneous emphysema, pneumoperitoneum,pneumothorax, and even pneumopericardium. The incidenceof diving-related pneumomediastinum is nonethelessunknown.Diagnosis of pneumomediastinum is largely based onclinical findings and imaging. In most cases, it can bedemonstrated on routine chest X-ray, although the diagno-sis may be missed in up to 30% of cases, especially whenit is mild. Computed tomography of the thorax increasesthe chance of diagnosis and provides additional informa-tion about any co-existent pathology.7,8Pneumomediastinum is not usually fatal althoughcases of tension pneumomediastinum have been reported.9Pneumothorax can be fatal when it occurs under waterand may rapidly progress to a life-threatening tensionpneumothorax when the diver surfaces (much more rapidlythan on land because of Boyle’s Law). Other diving-relatedproblems can also be serious. When simple pneumomedi-astinum is diagnosed, prompt recognition of the underlyingcondition and exclusion of potentially life-threateningconditions with similar symptoms (such as dissectingaortic aneurysm, angina pectoris, and mediastinitis) remainthe first priority. Divers may continue to dive despitemedical contra-indications. Physicians should thus beaware of the possibility of pneumomediastinum, its differ-ential diagnoses, as well as other potential complicationsthat arise from scuba diving.References1. Hamman LV. Spontaneous mediastinal emphysema. Bull JohnsHopkins Hosp 1939;64:1-21.2. Asplund CA, Howard TM, O’Connor FG. Spontaneous pneumo-mediastinum in a weightlifter. Curr Sports Med Rep 2003;2:63-4.3. Malik MH, Rammohan KS, Salama FD. An atypical presentation ofspontaneous pneumomediastinum. Eur J Emerg Med 2000;7:245-6.4. Mihos P, Potaris K, Gakidis I, Mazaris E, Sarras E, Kontos Z.Sports-related spontaneous pneumomediastinum. Ann Thorac Surg2004;78:983-6.5. Oh ST, Kim W, Jeon HM, et al. Massive pneumoperitoneum afterscuba diving. J Korean Med Sci 2003;18:281-3.6. Taylor DM, O’Toole KS, Ryan CM. Experienced scuba divers inAustralia and the United States suffer considerable injury andmorbidity. Wilderness Environ Med 2003;14:83-8.7. Gardikis  S ,  Tsalkidis  A,  Limas C,  e t  a l .  Spontaneouspneumomediastinum: is a chest X-ray sufficient? Minerva Pediatr2003;55:293-6.8. Kaneki T, Kubo K, Kawashima A, Koizumi T, Sekiguchi M, Sone S.Spontaneous pneumomediastinum in 33 patients: yield of chestcomputed tomography for the diagnosis of the mild type. Respiration2000;67:408-11.9. Kizer KW, MacQuarrie MB. Pulmonary air leaks resulting fromoutdoor sports. A clinical series and literature review. Am J SportsMed 1999;27:517-20.Fig. Computed tomographic scan showing obviouspneumomediastinum

Spontaneous pneumomediastinum in a scuba diver

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Spontaneous pneumomediastinum in a scuba diver

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