Working Diagnosis:
Spontaneous Exertional Pneumomediastinum

Treatment:
In the emergency room the patient was diagnosed with spontaneous exertional pneumomediastinum. She was deemed stable and discharged to follow-up with pulmonology as an outpatient. Pulmonology evaluated her and recommended her to not fly for 4 weeks. This recommendation prevented her from participating in tournaments that required extensive travel.

Outcome:
A repeat CT scan demonstrated resolution of the pneumomediastinum, and she was cleared to return to play with no long-term sequelae.

Author's Comments:
Pneumomediastinum is defined as free air that has infiltrated the mediastinum through the lungs, trachea, or esophagus. The most common mechanism of injury is alveolar rupture, though the textbook mechanism is forceful vomiting (i.e. Boerhaave syndrome), but any increase in intrathoracic pressure is a risk factor.(1)
Retrosternal chest pain is the most common presenting symptom, occurring in 60-100% of patients. Dyspnea (75%) and coughing (80%) are the next most common. Neck pain (36%) can occur with tracking of the air cephalad. (2)

The epidemiology is rare, but seen more in young (mean age 25.5 years) tall men with low BMI (76% of cases). Asthma and alcohol related emesis account each for 25% of cases. Approximately 10% of cases are related to physical activity.(1)

Diagnostic testing usually starts with radiographs, Xray identifies mediastinal air in 52-90% of cases. CT is the gold-standard for diagnosis and bronchoscopy and EGD are typically not required.(1)

Pneumomediastinum is typically self-limiting and complications are rare. Prophylactic antibiotics are used for trauma or instrumentation. Hospitalization criteria include distress, hypoxic, or fever (concern for mediastinal infection).(1,3)

When we look at the literature regarding sports specific concerns, the offerings regarding when to fly and return to sports are sparse. And this makes sense given the rare diagnosis.

The concern with air travel is similar with divers as elevation increases, gas expands which could theoretically compress vital mediastinal structures. We have recommendations from the British Thoracic Society for spontaneous pneumothorax to wait for a week after radiographic resolution, but there were no recommendations for pneumomediastinum. (4)

The two highest quality papers we have are case series of athletes. Olson in 2012 evaluated case reports of spontaneous pneumomediastinum in collision athletes. In the paper he discusses the physiologic basis of withholding from air travel, and notes that even with small compromise in lung function, a healthy athlete would easily have the respiratory reserve capacity to accommodate. (5)
In regards to return to play, he notes there are obviously no guidelines, but concludes that the athlete can likely return after asymptomatic, usually within two weeks or less.

One other notable case series came from Greece. These athletes had fairly good follow-up, and the biggest takeaway from this paper that is complete radiographic resorption occurred by 8 days in all the patients. Further highlighting that these athletes can likely return to sport fairly quickly. (6)

Editor's Comments:
Pneumomediastinum is a rare, self limited condition defined by air extravasation to the mediastinal space. The most common symptoms are chest pain, dysphagia, and dyspnea. Thorough evaluation should be undertaken to rule out other serious medical conditions with similar symptoms, and contrast enhanced chest CT is considered the gold standard for diagnosis. Underlying predisposing factors should be evaluated including asthma, COPD, or injury to surrounding organs. Treatment is observation and symptomatic care as the condition rarely can progress to more serious problems including cardiac tamponade. Prior to patients flying there should be radiographic evidence of resolution.

References:
Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Strother E, Margolis M. Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. J Cardiothorac Surg. 2008;3:59. Published 2008 Nov 3. doi:10.1186/1749-8090-3-59
Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis. 2015;7(Suppl 1):S44-S49. doi:10.3978/j.issn.2072-1439.2015.01.11
Okada M, Adachi H, Shibuya Y, Ishikawa S, Hamabe Y. Diagnosis and treatment of patients with spontaneous pneumomediastinum. Respir Investig. 2014;52(1):36-40. doi:10.1016/j.resinv.2013.06.001
Ahmedzai S, Balfour-Lynn IM, Bewick T, et alManaging passengers with stable respiratory disease planning air travel: British Thoracic Society recommendationsThorax 2011;66:i1-i30.
Olson, Ronald P. MD Return to Collision Sport after Pneumomediastinum, Current Sports Medicine Reports: March/April 2012 - Volume 11 - Issue 2 - p 58-63 doi: 10.1249/JSR.0b013e3182499f55
Mihos P, Potaris K, Gakidis I, Mazaris E, Sarras E, Kontos Z. Sports-related spontaneous pneumomediastinum. Ann Thorac Surg. 2004 Sep;78(3):983-6. doi: 10.1016/j.athoracsur.2004.03.017. PMID: 15337032.

Return To The Case Studies List.