Download The Evaluation of Pneumomediastinum in Blunt Trauma Patients

The Journal of TRAUMA威 Injury, Infection, and Critical Care
The Evaluation of Pneumomediastinum in Blunt
Trauma Patients
Sharmila Dissanaike, MD, Sherene Shalhub, MD, MPH, and Gregory J. Jurkovich, MD, FACS
Background: Pneumomediastinum
occurs in up to 10% of patients with blunt
thoracic and cervical trauma. Mandatory
evaluation of all patients with bronchoscopy and esophageal imaging to exclude a
major injury has been recommended.
There is little data on the safety or efficacy
of this approach. We evaluated the incidence of major injuries associated with
pneumomediastinum, the accuracy of diagnostic modalities, and the results of observation versus aggressive evaluation.
Methods: Medical records of all blunt
trauma patients diagnosed with pneumomediastinum and/or aerodigestive tract injury
between 1998 and 2005 were reviewed. The
patient’s hospital course was reviewed for
demographic data, admission diagnoses, diagnostic imaging and procedures, opera-
tions, missed injuries, length of stay, and
mortality.
Results: The review identified a total
of 136 patients with pneumomediastinum,
and an additional 22 patients with thoracic aerodigestive tract injuries but without pneumomediastinum. Only patients
with pneumomediastinum were considered in subsequent analysis. Pneumomediastinum was detected by CT scan in all
136 (100%) patients, although identified
on plain radiograph in only 20 (15%) patients. Computed tomography findings
were suspicious for a major aerodigestive
tract injury in 27 (20%) patients. Ten
(37%) of these 27 patients had an injury
requiring operative intervention: five
(4%) laryngeal injuries, three (2%) tracheal
disruptions, and two (1%) esophageal per-
forations. Eighty-one patients (60%) never
had endoscopic evaluation. There were no
delayed diagnoses, missed injuries, or complications in the observation-only cohort.
The overall sensitivity and specificity of CT
scan for major aerodigestive tract injury
was 100% and 85%, respectively.
Conclusion: Major airway or esophageal injury is an uncommon cause of pneumomediastinum. CT scan was able to identify
patients at high risk for aerodigestive injury in all cases, and should be the preferred screening tool for airway injury in
patients with pneumomediastinum.
Key Words: Pneumomediastinum,
Blunt chest trauma, Tracheal injury, Bronchial injury, Laryngeal injury, Esophageal
injury.
J Trauma. 2008;65:1340–1345.
P
neumomediastinum may occur in up to 10% of patients
with severe blunt thoracic and cervical trauma.1 Given
the recent increase in the use of routine computed
tomography (CT) scanning in trauma patients, the incidence
of asymptomatic pneumomediastinum is likely to increase.
Most pneumomediastinum has a benign etiology, caused by
extension of a pneumothorax through a pleural tear, air dissection around the bronchovascular sheath (the Macklin
effect2), or microperforations that are not clinically apparent.
However, there is a small but well-documented incidence of
major injury to the larynx, trachea, or bronchi, and rarely the
esophagus in these patients.3 Many authors hence recommend
mandatory endoscopy and/or esophagography for the evaluation of all pneumomediastinum patients to exclude a major
aerodigestive tract injury.4 There is little data on the efficacy
Submitted for publication March 8, 2007.
Accepted for publication January 18, 2008.
Copyright © 2008 by Lippincott Williams & Wilkins
From the Division of Trauma and Critical Care Surgery, Harborview
Medical Center, University of Washington, Seattle, Washington.
No outside sources of support, including pharmaceutical or industry
support, were received for this study.
Presented at the Seattle Surgical Society Meeting, February 2, 2007.
Address for reprints: Gregory J. Jurkovich, MD, FACS, Division of
Trauma and Critical Care, Department of Surgery, Harborview Medical
Center, 325 Ninth Avenue, Seattle, WA 98104; email: [email protected].
DOI: 10.1097/TA.0b013e318169cd24
1340
of this approach. We evaluated the incidence of major thoracic aerodigestive tract injuries associated with pneumomediastinum in our patient population, the accuracy of various
diagnostic modes, and the results of watchful waiting versus
aggressive evaluation.
MATERIALS AND METHODS
Patient Selection and Data Collection
We performed a retrospective chart review of all blunt
trauma patients admitted to the Harborview Medical Center,
between January 1998 and July 2005, with a diagnosis of
pneumomediastinum. Harborview Medical Center is the primary Level I Trauma Center for a four-state region, with
approximately 4,000 blunt trauma admissions each year.
Trauma registry database was used to identify patients
based on ICD-9 coding on discharge. A waiver of consent
was obtained from the University of Washington Institutional
Review Board for Human Subjects Research.
All charts with ICD-9 codes 518.1 (pneumomediastinum, interstitial, or mediastinal emphysema) and 958.7 (traumatic
emphysema) were selected. These charts were cross-referenced
with radiologic findings of pneumomediastinum by chest or
neck radiograph or CT within this time period. Charts that did
not have pneumomediastinum documented by an attending
radiologist during their admission were excluded from our
primary analysis. We further reviewed the trauma registry for
all blunt trauma patients with ICD-9 codes 807 (laryngeal/
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Evaluation of Pneumomediastinum in Blunt Trauma Patients
tracheal injury), 862 (intrathoracic bronchial or esophageal
injury), and 874 (open fracture or wound, larynx or trachea)
to ensure that we did not miss any diagnoses of either pneumomediastinum or aerodigestive tract injury during this time
period.
Information was collected on mechanism of injury, age,
sex, symptoms and signs on arrival, and intubation before
arrival. The patient’s hospital course was reviewed for diagnostic imaging, procedures, and operations. Primary outcomes were aerodigestive tract injuries, length of stay, and
mortality. Mortality was defined as death before hospital
discharge.
Statistical Analysis
Categorical variables were analyzed using Fisher’s exact
test. Mann–Whitney U test was used for univariate analysis
of continuous variables. Two-tailed p values and 95% confidence intervals (CI) were used and actual values are presented. Statistical significance was defined as p ⬍ 0.05.
Statistical analysis was performed using GraphPad Software
(San Diego, CA).
RESULTS
A total of 136 blunt trauma patients were diagnosed with
pneumomediastinum during the study period. A further 22
patients with aerodigestive tract injury but without pneumomediastinum were also identified, and are described separately at the end of this section. These patients were not
included in our primary analysis.
patients sustained focal neck injury and four (3%) patients
had isolated chest trauma. Forty-three (32%) patients were
transferred from another institution, and 71 (52%) patients
arrived intubated. Pneumothorax was the most common associated diagnosis for the entire cohort.
Mean hospital length of stay was 11 days, but length of
stay was significantly shorter for patients with isolated neck
injury versus thoracic injuries (2 days vs. 12 days, p ⫽ 0.04).
There were four deaths. One patient died shortly after admission because of massive exsanguination from abdominal and
thoracic injuries, and one patient had life support withdrawn
because of severe brain injury. Two patients died from multisystem organ failure and septic complications. There was no
evidence based on chart review that missed aerodigestive
tract injury as a factor in any of these deaths.
Clinical Signs and Symptoms
Table 2 describes the common clinical findings in the
study group. Crepitus was the most common sign in all
patients. Hoarseness was significantly more common in
patients with isolated neck trauma. Table 3 describes the
sensitivity and specificity of the clinical findings for major
aerodigestive tract injury. Hoarseness was the most specific
symptom, and crepitus was the most sensitive sign in patients
with aerodigestive injury. There is no specific institutional
protocol for the initial diagnostic modalities of pneumomediastinum, and patients were evaluated according to attending
surgeons discretion.
Imaging Studies—Radiography and CT Scanning
Patient Characteristics and Outcome
Table 1 describes the characteristics and mechanism of
injury of the 136 patients with pneumomediastinum. The
patients were mostly men (n ⫽ 99, 73%), reflective of the
general trauma population. The majority of patients (n ⫽ 79,
58%) were victims of motor vehicle collisions. Seven (5%)
Table 1 Characteristics of Patients With
Pneumomediastinum After Blunt Trauma
Number of patients
Age: mean, SEM
Male sex
Mechanism of injury
Motor vehicle collision
Motor cycle/all-terrain vehicle
Fall
Isolated blow to chest
Handlebar injury to neck
Isolated blow to neck
Hanging
Associated injuries
Pneumothorax
Hemothorax
Sternal fracture
Hospital length of stay, mean (SEM)
Mortality
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136
34 (⫾1.5) yr
99 (73%)
79 (58%)
17 (12.5%)
29 (21%)
4 (3%)
2 (1.5%)
4 (3%)
1 (1%)
92 (68%)
22 (16%)
8 (6%)
11 d (⫾1)
4 (3%)
The majority (n ⫽ 133, 98%) of patients had intravenous
contrast-enhanced CT of the chest, neck or both performed.
Sixty-nine (51%) patients had CT of both chest and neck, 33
Table 2 Clinical Presentation, Injuries, and Outcome
in Patients With Pneumomediastinum
Signs and Symptoms
All Patients
(n ⫽ 136)
Isolated Neck Injury
(n ⫽ 7)
Crepitus
Chest pain
Dyspnea
Hoarseness
Sternal tenderness
Airway injury
Esophageal injury
47 (35%)
33 (24%)
20 (15%)
11 (8%)
4 (3%)
8 (6%)
2 (1.5%)
4 (57%)
0
2 (29%)
3 (43%)
0
2 (29%)
0
p
0.25
0.35
0.25
0.02
0.077
Table 3 Sensitivity and Specificity of Various
Components of Physical Examination for Aerodigestive
Injury in Patients With Pneumomediastinum
Crepitus
Dyspnea
Hoarseness
Chest pain
Sensitivity (%) (95% CI)
Specificity (%) (95% CI)
66.7 (30.9–91.0)
44.4 (15.3–77.3)
33.3 (9.0–69.1)
33.3 (9.0–69.1)
68.6 (59.4–76.6)
86.8 (79.1–92.0)
94.2 (88.0–97.4)
75.2 (66.4–82.4)
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The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 1. CT image, arrow shows tracheal injury near the carina.
Fig. 3. CT image, arrow shows location of anterior laryngeal
injury.
for aerodigestive tract injury. CT scan was able to identify the
precise location of injury in all three tracheal injuries (100%)
and four of the five (80%) laryngeal fractures. CT scan was
able to identify both cases (100%) of esophageal injury,
although not the precise location.
There were 17 (13%) false-positive CT scans, in that no
significant injury was found on further investigation. There
were no false-negative CT scans, i.e., injuries that were
missed on CT scan and presented later with clinical symptoms. The sensitivity and specificity of CT scanning for
major aerodigestive tract injury in our series was 100% (CI
69 –100) and 85% (CI 80 –92.5), respectively.
Specific Investigations for Pneumomediastinum—
Endoscopy and Contrast Esophagram
Fig. 2. CT image, arrow shows right posterior tracheal injury.
(24%) had CT of the neck only, and 31 (23%) had CT of the
chest only. The remaining three (2%) patients had pneumomediastinum identified by chest radiograph and never
received thoracic CT imaging. Pneumomediastinum was
identified on plain chest or cervical spine radiograph in only
20 (15%) patients.
CT findings were suspicious for a major airway or
esophageal injury in 27 (20%) patients. Suspicious CT findings included airway irregularity, disruption of the cartilage
or tracheal wall, (Figs. 1–3) focal thickening or indistinctness
of the trachea or main bronchi, laryngeal disruption, and
concurrent pneumo-peritoneum on CT of the abdomen. Massive pneumomediastinum despite adequate tube drainage of
pneumothoraces was also considered as a suspicious finding
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Thirty-eight (28%) patients underwent bronchoscopy, 14
(10%) patients underwent direct or indirect laryngoscopy,
and 9 (7%) patients underwent esophagoscopy. This includes
procedures performed in the operating room to confirm and
further evaluate injuries already identified by CT scan. Thirtyfive (26%) patients had contrast esophagram to exclude perforation. There were no complications from any of the diagnostic
procedures noted in our chart review. All patients had undergone
prior CT imaging.
Results of Clinical Observation
Eighty-one (60%) patients were admitted for observation
(78 with CT scan, 3 with plain x-ray only) with no endoscopic or esophagography evaluation. None of these patients
had a missed injury or suffered any complications related to
the pneumomediastinum. There were no diagnostic delays.
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Evaluation of Pneumomediastinum in Blunt Trauma Patients
Patients With Significant Injury Requiring Operation
Ten (7%) patients in this series were confirmed to have
a major aerodigestive injury related to the pneumomediastinum that required operative intervention. Pneumomediastinum was noted on chest radiograph in 5 of these 10 (50%)
patients, with subcutaneous emphysema in 4 (40%) patients.
All 10 patients had documented CT findings suspicious for
aerodigestive tract injury. Airway injury was the cause of
pneumomediastinum in eight cases, and esophageal injury in
two cases. In seven of the eight cases of airway injury
(87.5%), CT scan was able to localize the site of injury. In both
cases of esophageal injury CT scan was diagnostic, although the
exact location of the injury was not identified preoperatively.
Immediate surgical repair was performed in all cases with good
recovery and no postoperative complications.
Laryngeal Injury
There were five laryngeal injuries, primarily fractures of
the cricoid cartilage, arytenoids, and thyroid cartilages. Two
cases were in the isolated trauma group, the only injuries
found in this cohort. One patient survived an attempted hanging, and the other had sustained a blow to the neck.
The other three injuries were caused by motor vehicle
collisions. All injuries were confirmed with intraoperative
laryngoscopy and bronchoscopy, and underwent surgical
treatment. One patient was treated with tracheostomy alone,
whereas the others had primary repair of the defect without
tracheostomy.
Tracheobronchial Injury
A 3-cm tracheal rupture extending onto the right mainstem bronchus was found on a 37-year-old woman after
motor vehicle collision. The second injury was in an 18-yearold man after motor vehicle collision with a small tear noted
at the carina extending 0.5 cm onto the right main bronchus.
The final injury was in a 43-year-old woman presenting with
persistent large pneumothoraces, despite thoracostomy drainage and massive subcutaneous emphysema after motor vehicle collision. She had a 4-cm laceration at the posterior
trachea, extending 0.75 cm onto the right main bronchus. All
injuries were identified by discontinuity of the tracheal wall
on CT scan, followed by confirmatory bronchoscopy, urgent
open thoracotomy, and repair.
Esophageal Injury
Two esophageal perforations were identified. The first
was in a 12-year-old boy presenting nonintubated after a
motorcycle crash. No specific signs or symptoms related to
pneumomediastinum were noted. The injury was a perforation just proximal to the gastroesophageal junction with
adjacent stomach laceration. The patient had concomitant
pneumoperitoneum on CT scan. The second patient, a 58year-old woman arriving intubated after a motor vehicle collision, had a perforation at the mid-thoracic esophagus. CT
Volume 65 • Number 6
scan revealed air tracking along the esophagus. Both injuries
were confirmed with esophagram preoperatively and treated
with primary repair and wide drainage.
Patients With Aerodigestive Injuries
Without Pneumomediastinum
There were 22 patients between 1998 and 2005 who
were diagnosed with aerodigestive tract injuries without evidence of pneumomediastinum. The airway injuries were all
laryngeal fractures. No clinically evident tracheobronchial
injuries without pneumomediastinum were diagnosed during
this time period. Four (18%) patients sustained karate-style
blows to the neck, and four (18%) other patients had handlebar injuries from bicycle/motorcycle mishaps as the mechanism for anterior laryngeal fractures. The remainder of airway
injuries (62%) occurred from high-speed motor vehicle collisions. There was one (4.5%) esophageal injury in this group.
An additional seven blunt trauma patients had iatrogenic
airway injuries because of failed attempts at intubation or
surgical airway in the field, requiring operative revision.
DISCUSSION
Our study demonstrates the rarity of major aerodigestive
tract injury as a cause of pneumomediastinum. Approximately,
7% of patients had an injury requiring operative intervention.
Airway injury was present in 6%, and esophageal injury in only
1% of our patient cohort. The increased utilization of routine
trauma CT scans is likely to increase the number of patients
diagnosed with incidental pneumomediastinum.
It is evident that in the majority of cases, pneumomediastinum is a benign finding. Almost 70% of our patients had
concomitant pneumothorax. Dissection of the pneumothorax
via a pleural tear is well described, and a likely mechanism of
pneumomediastinum. The Macklin effect, first described in
1939, is caused by air dissecting medially along bronchovascular sheaths after alveolar rupture. This has been noted to
occur in up to 39% of trauma patients.2 The effect has been
documented not only in trauma but also in asthma crises,
positive pressure ventilation, and after Valsalva maneuvers.5
Improvements in CT technology have allowed radiologists to
diagnose this effect by identifying air tracking contiguous to
pulmonary vessels and bronchi. However, trauma patients
often have multiple abnormalities on chest CT scan, which
render this diagnosis impractical in the acute setting. Additionally, the mere presence of the Macklin effect does not in
itself exclude a synchronous airway injury.
Many authors have suggested that bronchoscopy be mandatory for all patients4,6,7 given the high morbidity of tracheal
disruption.8 However, given the low incidence of actual injury, this would subject a large number of patients to an
invasive diagnostic procedure with low yield. Although there
were no complications from endoscopy in this series, they
can and do occur, and it is a potentially unnecessary use of
limited resources. The challenge facing the trauma surgeon is
how to select those patients who are at increased risk of
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The Journal of TRAUMA威 Injury, Infection, and Critical Care
Blunt trauma with pneumomediastinum on CXR/CT
CT neck and chest
with IV contrast
High suspicion for
esophageal injury
High suspicion for
airway injury
Bronchoscopy and/ or
Esophagoscopy and/ or
Esophagram
Laryngoscopy
--
+
Observation
Low suspicion for
airway or esophageal
injury
Evaluate for operation
--
Observation
Fig. 4. Algorithm showing evaluation of blunt trauma patients with
pneumomediastinum. CT, computed tomography scan; CXR, chest
radiograph.
severe tracheal disruption or esophageal injury for further
evaluation. On the basis of our findings, we offer the following algorithm to assist with the decision-making process (Fig. 4).
Certain mechanisms of trauma may place patients at
higher risk of airway injury. We were concerned that patients
with isolated blows to the neck may be more likely to suffer
significant airway disruption than patients with more “diffuse” mechanisms. Our isolated neck trauma cohort was five
times more likely to have laryngeal fractures (29% vs. 5%)
than the rest of the study population. Although this did not
reach statistical significance ( p ⫽ 0.077) because of the small
numbers of injuries in the series, we nevertheless think that
this group may warrant a higher index of suspicion for airway
injury.
We examined the utility of clinical signs to select patients for further evaluation. Crepitus was the most prevalent
sign in all patients with pneumomediastinum. In addition to
being common in patients with benign causes of pneumomediastinum, many of our patients had concomitant pneumothorax as a likely cause. Therefore, it is of less value in
determining who requires further investigation for pneumomediastinum. Hoarseness and dyspnea had specificity for
airway injury approaching 90% in our cohort, and further
investigation is clearly warranted in these patients. Interestingly, sternal tenderness was a rare finding overall, being
present in only 3% of patients. This correlates with the likely
mechanism of pneumomediastinum being an increase in intrathoracic pressure rather than a result of direct mediastinal
trauma.
Because many patients remain intubated during their first
24 hours of admission, the value of clinical findings is somewhat limited. CT scan would be the logical screening tool in
this patient population. The majority of these patients will
have indications to receive a CT scan shortly after admission
because of their injury mechanism. Kunisch-Hoppe et al. in a
1344
retrospective review performed between 1992 and 1998
found CT scan to be unreliable, confirming tracheal injury in
only one of nine cases. However, the technology used in
modern CT scanners has improved significantly since that
period. The development of helical CT scanning and highspeed scanners allows the acquisition of contiguous patient
data and produces high-quality three-dimension (3D) reconstructions. In our patient population, CT was able to accurately identify all patients who had significant injuries. The
overall specificity for excluding injury was 85%. The small
number of total injuries prevented us from attempting an
analysis of sensitivity or specificity for different injury sites
and time periods. The current generation of helical CT scanners may have a significantly higher accuracy than reported
in previous literature, as suggested by Moriwaki et al.9 They
were able to accurately identify six tracheal injuries in their
series of blunt and penetrating trauma using 3D CT tracheography. Chen et al.10 performed a retrospective study analyzing the
sensitivity of helical CT in detecting traumatic tracheal rupture. They were able to identify tracheal rupture on CT by
discontinuity of the tracheal wall, deformity or herniation of
the endotracheal tube balloon. Using these criteria, the sensitivity of CT in their study was 85%. Scaglione et al.11 report
94% accuracy in localizing the site of tracheobronchial injuries from blunt trauma in a recent series. Their CT findings
were similar, including displacement of the endotracheal balloon, discontinuity of the airway wall, and focal enlargement
of the airway.
There were no missed injuries or other complications in
patients who did not receive mandatory bronchoscopy in our
cohort. It is possible that injuries too subtle to be identified on
CT scan may heal spontaneously, and that we would have
discovered a larger number of injuries had we performed
mandatory bronchoscopy. Whether minor airway injuries require surgical treatment is a matter of debate. Several authors
have described the successful non-operative management of
iatrogenic tracheal injuries.12,13 Gomez-Caro et al.14 recently
described the non-operative management of traumatic tracheobronchial injuries and shown this to be effective treatment, especially in minimally symptomatic membranous
injuries. In the largest review of tracheobronchial injuries
with 265 patients, Kiser et al.15 found that patients who do
not manifest acute symptoms may present several months
later with chronic obstructive symptoms distal to the injury.
However, patients in that review who underwent delayed
diagnosis and repair of their injury did as well, if not better,
than those patients who had immediate repair. In minimally
symptomatic patients, airway injuries too small to be detected
by CT scan may represent a population that would not require
operative treatment.
Esophageal injuries are a rare cause of pneumomediastinum from blunt trauma. The existing literature consists
largely of case reports, with fewer than 20 reported cases.16
We had a 1.5% incidence of esophageal injuries in our series,
only two cases, and both were diagnosed by CT scan and
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Evaluation of Pneumomediastinum in Blunt Trauma Patients
confirmed by esophagram. Suggestive findings on CT scan
without oral contrast included air tracking along the esophagus and in one case, pneumoperitoneum. The accuracy of
multidetector row CT scan in detecting esophageal perforation has been demonstrated in the setting of malignancy,
iatrogenic and traumatic injury.17,18 The addition of oral
contrast to the CT scan may increase the accuracy of detecting esophageal perforation, and enable diagnosis of aerodigestive tract injury in patients with pneumomediastinum,
with a single study. Given this very low incidence and the
accuracy of advanced CT imaging, we think it is unnecessary
to continue to utilize esophagography or esophagoscopy in
the routine evaluation of blunt trauma pneumomediastinum
given a negative and unsuspicious thoracic CT scan. We do
recognize that esophageal injury has disastrous consequences
if not diagnosed and treated in a rapid fashion, and others
may continue to prefer routine esophageal evaluation in all
patients with pneumomediastinum.
4.
5.
6.
7.
8.
9.
10.
11.
CONCLUSION
Routine CT scanning of trauma patients has resulted in
an increase in the diagnosis of pneumomediastinum. A major
aerodigestive tract injury is seen in approximately 7% of
patients with blunt trauma pneumomediastinum. CT scan is
useful in identifying patients with a high likelihood of serious
aerodigestive tract injury, and may be used as the initial
screening tool to distinguish patients who can be safely observed, and those in need of further evaluation.
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