Abstract
Pneumomediastinum and subcutaneous emphysema are rare presentations of an airway foreign body. Only a handful of other cases have been reported in the English literature. We present a case of a 2 year old female who presented with wheezing and a dry cough. Following a breathing treatment with a non-rebreather mask, she developed right sided facial subcutaneous emphysema. The following day, after an episode of crying, the subcutaneous emphysema rapidly progressed to involve the anterior chest wall, shoulders, neck and face. Rigid bronchoscopy was emergently performed and a ball-valving, soft foreign body was removed from the right bronchus. A chest tube was placed, and the patient was successfully extubated the following day. When faced with a pediatric patient presenting with subcutaneous emphysema or pneumomediastinum of unknown origin, the pediatrician and otolaryngologist should consider the possibility of an airway foreign body. Management involves emergent airway evaluation in the operating room, removal of the foreign body, placement of a chest tube if pneumomediastinum is present, and supportive care with reflux medications and intravenous steroids.
1
Introduction
Spontaneous pneumomediastinum (SPM) is a rare occurrence in children. It develops from the spread of air into the mediastinum. The reported incidence of SPM ranges from 1 in 800 to 1 in 42,000 . Asthma is the most frequent cause of SPM in children, with a peak incidence between 6 months and 3 years of age, and a second peak in older children and adolescents . Pathogenesis involves rupture of a pulmonary alveolus along the bronchioles or pulmonary vessels. Subcutaneous emphysema (SCE) results when air dissects along planes of the mediastinum to subcutaneous tissues of the thorax, neck and upper limbs . This occurs at a rate of 76% of SPM patients . Other causes include esophageal rupture, infection, trauma, and foreign body aspiration. Pneumomediastinum (PM) resulting from foreign body aspiration is very uncommon with only a handful of case reports in the English literature. However, its identification is critical in preventing life-threatening complications. We describe here, a case of foreign body aspiration that led to SCE and PM and the exacerbation of symptoms with medical therapy using breathing treatments.
3
Case report
A 2 ½ year old female was initially evaluated by her pediatrician for persistent dry cough and wheezing. She had no prior history of asthma or trauma. She was seen chewing on erasers and playing with play-dough previously, but there was no observed incident of foreign body aspiration or choking. She received a nebulized treatment of ipratropium/albuterol at the pediatrician’s office, and her wheezing improved. However, the following morning, her symptoms recurred.
She was admitted to the hospital for further work-up. Her initial chest x-ray was not noted to have any abnormal findings. The next day, as the patient received another treatment of an aerosolized bronchodilator and steroids through a non-rebreather mask, she slowly developed right facial swelling that progressed from the neck up to the right periorbita. An ENT consult was ordered by the pediatrician. The patient was not in any respiratory distress or pain at this time. On palpation, her right cheek was cold and firm to touch. A repeat chest x-ray was performed and revealed PM and SCE ( Fig. 1 ). The patient incidentally lost IV access, and during efforts to replace her IV, the patient became distressed with increased work of breathing and crying that led to increased intrathoracic pressures. The SCE and swelling worsened within minutes with spread of subcutaneous air across the left face, neck shoulders and chest. The patient was transferred to the operating room for an emergency airway evaluation.
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