|Year : 2015 | Volume
| Issue : 3 | Page : 344-346
Coughing leading to spontaneous pneumomediastinum and subcutaneous emphysema in a young male
Ruchi Sachdeva1, Sandeep Sachdeva2
1 Department of TB and Respiratory Diseases, PGIMS, Rohtak, Haryana, India
2 Department of Community Medicine, PGIMS, Rohtak, Haryana, India
|Date of Web Publication||15-May-2015|
Department of TB and Respiratory Diseases, PGIMS, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
A 20-year male college student, nonsmoker, nonalcoholic, average built presented with sudden onset cough since last 1 day along with diffuse swelling in the neck, difficulty in swallowing both liquids and solid since 1 day. There was history of rhinorrhea alternating with nasal block intermittently with change of seasons since last 3-4 years. There was no history of weight lifting, drug intake, tuberculosis or trauma, or family history of allergy. A case report of self-limiting spontaneous pneumomediastinum following a sudden bout of coughing with no underlying lung lesion is being reported.
Keywords: Asthma, coughing, fistulas, inhaled drug use, invasive medical procedures, physical exertion, positive-pressure ventilation, sneezing, trauma, valsalva maneuver, vomiting
|How to cite this article:|
Sachdeva R, Sachdeva S. Coughing leading to spontaneous pneumomediastinum and subcutaneous emphysema in a young male. Med J DY Patil Univ 2015;8:344-6
| Introduction|| |
Pneumomediastinum is defined by the presence of air in the mediastinum. The main causes are trauma, asthma, positive-pressure ventilation, coughing, sneezing, vomiting, physical exertion, inhaled drug use, invasive medical procedures (cervical, thoracic, or abdominal), tracheobronchial or esophageal-bronchial fistulas and valsalva maneuver during labor and childbirth. ,, It rarely occurs in the absence of pulmonary disease or other precipitating factors.  Spontaneous pneumomediastinum (SPM) is a self-limiting condition, rare in adults having predominance in young male individuals with a male/female ratio of 8:1.  We report a case of SPM in a young male following a bout of sudden coughing with no underlying lung lesion.
| Case Report|| |
A 20-year male college student, nonsmoker, nonalcoholic, average built presented with sudden onset cough since last 1 day along with diffuse swelling in the neck, difficulty in swallowing both liquids and solid since 1 day. There was history of rhinorrhea alternating with nasal block intermittently with change of seasons since last 3-4 years. There was no history of weight lifting, drug intake, tuberculosis, trauma, or family history of allergy. There was also no personal history of cyanosis, fever, chest pain, breathlessness, orthopnea, and paroxysmal nocturnal dyspnea. On examination, patient comfortably speaking with the presence of diffuse subcutaneous swelling and bilateral palpable crepitus on the anterior aspect of neck, extending from clavicle till the angle of mandible. Pallor, icterus, cyanosis, jugular venous pressure, lymphadenopathy, and pedal edema were negative. Chest examination was within normal limits along with bilateral vesicular breath sounds with no added sounds. At presentation vitals and blood/urine investigations were within normal limits. Serum IgE-401 (normal range: 1.0-200.0) IU/ml. Chest X-ray showed bilateral subcutaneous emphysema. Para nasal sinuses (waters view) revealed right maxillary sinusitis. Computed tomography (thorax) revealed the presence of pneumomediastinum with bilateral subcutaneous emphysema; trachea and main bronchi normal; no pleural effusion with normal underlying lung parenchyma [Figure 1],[Figure 2] and [Figure 3]. Pulmonary function test: Forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC)-72.17; FEV 1 -68%; FVC-83%. Patient was managed conservatively on high flow oxygen therapy, antihistaminic drugs, bronchodilator, and antibiotics.
|Figure 1: Section 1-computed tomography (thorax) revealed the presence of pneumomediastinum with B/L subcutaneous emphysema|
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| Discussion|| |
Pneumomediastinum an uncommon condition was the first reported in 1618 when Louise Bourgeois, midwife of the French royal family, observed a case of subcutaneous emphysema in a woman after labor.  The first contemporary report of SPM was described by Louis Hamman characterized by a "curious loud bubbling, crackling sound synchronized with the heartbeat" (Hamman's sign).  SPM is often referred to as respiratory pneumomediastinum because in most of the cases, it is caused by leakage of air from the respiratory tract. The leakage results from pressure gradient existing between the periphery of the lung and the hilus, which leads to air dissection along the vascular sheet to the hilum, known as Macklin and Macklin phenomenon. 
Cough is an explosive expiration that provides a normal protective mechanism for clearing the trachea-bronchial tree of secretions and foreign material. However, sudden increase in intra-thoracic pressure during coughing is a risk factor of alveolar over distension and rupture. However, forceful contraction of expiratory muscles limit the expansion of lungs to their total lung capacity by splinting the chest wall and prevents volutrauma that may occur if it was increased causing alveolar volume disruption of alveolar walls.  The transient increase in intrapulmonary pressure during coughing may also cause alveolar rupture. Coughing is usually uneventful, but occasionally results in microscopic alveolar rupture. 
The clinical manifestations of SPM are variable and depend upon the volume of air within the mediastinum. The patient may remain asymptomatic or may have symptoms such as chest pain, dyspnea, dysphagia, dysphonia, coughing, and/or neck swelling. Our patient had neck swelling and dysphagia after coughing. Chest radiographs are usually sufficient to diagnose SPM. The radiographic signs of SPM depends upon the projection of normal mediastinal anatomic structures outlined by air and include the thymic sail sign, ring around the artery sign, tubular artery sign, double bronchial wall sign, continuous diaphragm sign, and the extra-pleural sign.  All signs may not be present in any one case. A computed tomography scan can detect even a minimal SPM when the chest radiograph may be normal. Conservative management is the mainstay therapy and most cases have a favorable clinical course with complete passive re-absorption of air and low recurrence rate.  Complications rarely occur and include mediastinitis and/or pneumothorax/hypertensive pneumomediastinum, which may require surgical intervention.
| Acknowledgment|| |
The authors would like to thank Department of TB and Respiratory Diseases and Radiology, PGIMS, Rohtak, Haryana, India.
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[Figure 1], [Figure 2], [Figure 3]
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