Spontaneous Pneumomediastinum in Children: Underdiagnosis and Overtreatment

Abstract

Background: Spontaneous pneumomediastinum (SPM) is a rare and benign self-limiting condition characterized by the presence of air in the mediastinum without an apparent cause. Boerhaave syndrome, on the other hand, is a rare condition caused by spontaneous esophageal perforation due to severe vomiting. The mediastinum is a complex anatomical region housing vital organs, making clinical comprehension challenging. Objectives: There is no established approach to diagnosing and treating children with SPM. Despite similarities in the presence of air in the mediastinum, SPM and Boerhaave syndrome are distinct entities. However, the primary challenge for patients is ruling out esophageal perforation. We aimed to highlight this rare issue by presenting the results of our patient series to guide further examination in pediatric patients with mediastinal air. Methods: We included twenty-four pediatric patients diagnosed with SPM between 2014 and 2022. Demographic and clinical characteristics, diagnostic procedures, treatments, and follow-up details were retrospectively recorded. Results: The mean age of the twenty male and four female patients was 14 years. Common triggers included coughing (45%), increased physical exertion (33%), and retching/vomiting (8%). All patients experienced chest pain, with additional symptoms such as dyspnea (50%), neck pain (30%), and dysphagia (12%). Symptoms resolved within two days of hospitalization. Patients were often misdiagnosed and received inappropriate treatment at other centers before being transferred to our hospital. A fluoroscopic esophagogram conducted within an average of 22 hours from admission revealed no abnormalities. Oral feeding was withheld for an average of 28 hours. The mean duration of symptom-free hospitalization without treatment was 32 hours. Conclusions: It appears that emergency department physicians may lack familiarity with pneumomediastinum. Surgeons' concerns about missing Boerhaave's syndrome may lead to unnecessary tests, prolonged fasting, and hospital stays for patients with SPM.