Working Diagnosis:
Traumatic Pneumomediastinum with Pneumothorax

Treatment:
In the Emergency Department, approximately 90 minutes after the end of the game, the athlete started to experience chest and throat pain along with tachycardia and visible swelling across his neck and clavicles in addition to the right ear fullness and altered phonation. He was electively intubated to protect his airway and a chest tube was inserted due to his progressing diffuse subcutaneous emphysema with an unknown cause and increasing symptoms. He was subsequently admitted to the Intensive Care Unit (ICU) and observed while his pneumomediastinum and subcutaneous emphysema resolved. He was extubated, chest tube removed, and observed for a few additional days to ensure no recurrence of his presenting symptoms or imaging.

Outcome:
The athlete was released from the hospital and monitored by the team physician and cardiothoracic surgeon with serial chest x-rays Case Photo #3 . Two weeks post-injury, he began easing into aerobic activities. At four-weeks post-injury, he resumed weightlifting and sports specific noncontact activity. He was cleared for full contact six weeks post injury. X-rays remained unremarkable throughout his recovery and return to play progression. Following clearance, he rejoined his collegiate football team for their final game of the season and senior night.

Author's Comments:
When an athlete initially presents with scapular pain, especially in the face of repetitive trauma, it is important to conduct a comprehensive physical examination to prevent potential serious outcomes. Pneumomediastinum has been documented with collision sports with rapid spontaneous resolution or requiring hospitalization and monitoring. Athletes may present with substernal chest pain, pain with breathing, subcutaneous emphysema, or Hamman's sign or crunch. The extent of our athlete's subcutaneous emphysema caused his right ear fullness and altered voice. With the continued spread of subcutaneous emphysema and no identifiable cause for its presence (i.e., fractures), he was treated more aggressively in the hospital with elective intubation to protect his airway.
Return to play guidelines have not been established for pneumomediastinum but the extent of injury and any additional injuries would direct timeline and possible to return to sport. Shared decision making has been utilized by team physicians, athletes, and their families for the safe potential return of the student athlete to collision activities.
With serial negative imaging during a slow return to play progression starting with aerobic activity, weightlifting, throwing activities, and noncontact sport specific activities, our athlete was found to not be at any increased risk of returning to football at his previous position.

Editor's Comments:
Pneumomediastinum is an often-overlooked condition in the differential diagnosis when dealing with injuries of athletes participating in contact sports. A high degree of suspicion must be maintained for such a condition since it can lead to potentially catastrophic consequences.


If pneumomediastinum is suspected, transferring the athlete to a higher level of care such as an Emergency Department is the appropriate course of action since it allows for management of the athlete in a more controlled setting. The athlete in this case presented with symptoms of sore throat, altered phonation, ear fullness and subcutaneous emphysema. The team physician took appropriate action in transferring him to the Emergency Department for further evaluation after ensuring stability of the athlete.

References:
1. Iteen AJ, Bianchi W, Sharman T. Pneumomediastinum. (Updated 2023 May 1). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557440/

2.McKnight CL, Burns B. Pneumothorax. (Updated 2023 Feb 15). In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441885/

3. Mihos, P., Potaris, K., Gakidis, I., Mazaris, E., Sarras, E., & Kontos, Z. (2004). Sports-related spontaneous pneumomediastinum. The Annals of Thoracic Surgery, 78(3), 983–986. https://doi.org/10.1016/j.athoracsur.2004.03.017
4. Morgan, E. J., & Henderson, D. (1981). Pneumomediastinum as a complication of athletic competition. Thorax, 36(2), 155–156. https://doi.org/10.1136/thx.36.2.155
5. Olson, R. P. (2012). Return to Collision Sport after Pneumomediastinum. Current Sports Medicine Reports, 11(2), 58–63. https://doi.org/10.1249/jsr.0b013e3182499f55

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