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Spontaneous pneumomediastinum is characterized by the accumulation of air in the mediastinum with no identified cause. It is a rare and self-limiting condition. We report the case of a 32-year-old female patient with controlled bronchial asthma, who presented with spontaneous pneumomediastinum, with no precipitating event. The evolution is generally benign and the treatment is conservative. Symptomatic medication may be instituted.

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Introducción: el síndrome de Hamman es la aparición de neumomediastino espontáneo asociado a enfisema, patología poco frecuente en pediatría. Sus síntomas principales son dolor torácico agudo, disnea y enfisema subcutáneo. Objetivo: describir una experiencia clínica en la que se sospechó este síndrome analizando el proceso diagnóstico, estudios complementarios y el tratamiento. Caso clínico: varón de 4 años, con antecedentes personales de laringitis a repetición. Presenta laringitis aguda severa, requirió ventilación no invasiva por 12 horas. A las 24 horas del ingreso instaló de forma brusca estridor inspiratorio, dificultad respiratoria, edema de cuello y cara con crepitación a nivel de cuello y cara anterior del tórax que se fue extendiendo a ambos brazos. Se realiza radiografía de tórax que evidencia enfisema subcutáneo extenso. Se realiza tomografía de cuello y tórax que descarta lesión en vía aérea. Con el planteo de síndrome de Hamman en un niño que presentaba como factor predisponente el episodio de laringitis aguda, se decidió no continuar con estudios complementarios. Se realizó tratamiento fisiopatológico con buena evolución clínica. Alta a la semana del ingreso. Conclusiones: el diagnóstico en la urgencia del neumomediastino espontáneo puede representar un desafío, con una variedad de diagnósticos diferenciales potencialmente mortales. La alta sospecha permitirá realizar una evaluación clínica e imagenológica adecuada que permitan confirmar su diagnóstico y evitar procedimientos invasivos innecesarios.

Introduction: Hamman's syndrome involves the appearance of spontaneous pneumomediastinum associated with emphysema, a rare pathology in pediatrics. Its main symptoms include acute chest pain, dyspnea and subcutaneous emphysema. Objective: to describe a clinical case of this suspected syndrome by analyzing the diagnostic process, supplementary studies, and treatment. Clinical case: 4-year-old male with personal history of repeated laryngitis. He presented severe acute laryngitis, requiring non-invasive ventilation for 12 hours. Twenty-four hours after admission he developed abrupt inspiratory stridency, respiratory distress, neck, and face edema with crepitation at neck level and front of thorax spreading to both arms. A chest X-ray shows extensive subcutaneous emphysema. A neck and chest CT scan rules out airway injury. With the suggestion of Hamman's syndrome in a child who presented acute laryngitis as a predisposing factor the episode, it was decided not to continue with additional studies. Physio-pathological treatment was carried out with good clinical evolution. He was discharged a week after admission. Conclusions: diagnosis of spontaneous pneumomediastinum can be challenging in an emergency setting and having a variety of potentially life-threatening differential diagnoses. High suspicion levels will enable an adequate clinical and imaging assessment to confirm its diagnosis and avoid unnecessary invasive procedures.

Introdução: síndrome de Hammam é o aparecimento de pneumomediastino espontâneo associado ao enfisema, uma patologia rara na pediatria. Seus principais sintomas são dor aguda no peito, dispneia e enfisema subcutâneo. Objetivo: descrever um caso clínico com suspeita dessa síndrome por meio da análise do processo diagnóstico, estudos complementares e tratamento. Caso clínico: menino de 4 anos com histórico pessoal de laringite recorrente. Teve laringite aguda grave, o que exigiu ventilação não invasiva por 12 horas. Dentro de 24 horas após a internação, instalou-se abruptamente estridor inspirador, dificuldade respiratória, edema do pescoço e rosto com estalos ao nível do pescoço e face anterior do peito, estendido para ambos braços. Raios-x do tórax mostram enfisema subcutâneo extenso. Tomografia do pescoço e tórax exclui lesões nas vias aéreas. Com a sugestão da síndrome de Hammam em uma criança que apresentou como fator predisponente o episódio de laringite aguda, decidiu-se não continuar com estudos complementares. O tratamento fisiopatológico mostrou boa evolução clínica. A alta teve lugar dentro de uma semana da data da internação. Conclusões: o diagnóstico na urgência do pneumomediastino espontâneo pode representar um desafio, além do mais quando existem uma variedade de diagnósticos diferenciais que ameaçam a vida. A alta suspeita permitirá uma avaliação clínica e de imagem adequada para confirmar o diagnóstico e evitar procedimentos invasivos desnecessários.

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BACKGROUND: Pneumomediastinum is a rare complication of COVID-19 pneumonia, which may or may not be associated with invasive ventilatory support. Therefore, the report and findings associated with its evolution can be of great contribution in the management of this unknown disease. CASE PRESENTATION: Here, we present a series of four patients with severe pneumomediastinum requiring intensive care unit. These patients developed pneumomediastinum before or during orotracheal intubation (OTI) or without OTI. The four patients were three men and one woman with a mean age of 60.5 years (48-74 years). No patients had a known history of lung disease or traumatic events, except for one patient who had a history of smoking, but who was without parenchymal disease. All intubations were performed without complications. No cases of pneumomediastinum occurred after tracheostomy, and none of the patients had tomographic or bronchoscopic evidence of tracheal injury. Although the pneumomediastinum observed in our cases was apparently not related to a violation of the aerodigestive track, this complication was associated with a worse prognosis. CONCLUSION: Pneumomediastinum is a rare complication of COVID-19 pneumonia, and the most likely etiopathogenesis is severe pulmonary involvement, which may or may not be associated with invasive ventilatory support. Future studies with a greater number of cases should elucidate the relationship of pneumomediastinum to a probable prognostic factor.

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Background: Spontaneous pneumomediastinum is the presence of free air in the mediastinum that does not occur from direct thoracic or esophageal trauma. It is a very rare condition usually related to patients with asthma, respiratory infections, or foreign body aspiration. Only a few cases are reported to be associated with severe reflux events. Case report: We present the case of a 10-year-old female with spontaneous pneumomediastinum extending to the neck secondary to severe and persistent hiccups, with no history of asthma, trauma, surgery, acute infection, foreign body aspiration, and intense exercise with Vasalva. Conclusions: The irritation of the distal third of the esophagus produced severe and persistent episodes of hiccups that increased the intrathoracic pressure, which in turn triggered the pneumomediastinum by Macklin effect. The diagnosis is made with imaging studies. The treatment is conservative with resolution of the clinical picture between five and seven days after hospitalization.

Introducción: El neumomediastino espontáneo es la presencia de aire libre en el mediastino que no ocurre por un trauma torácico o esofágico directo. Es un padecimiento muy raro, que usualmente ocurre en pacientes con asma, infecciones respiratorias o aspiración de cuerpo extraño. Se reportan pocos casos asociados a eventos de singultos por reflujo grave. Caso clínico: Se presenta el caso de una paciente de 10 años con neumomediastino espontáneo y extensión al cuello secundario a un episodio grave y persistente de hipo sin antecedentes de asma, trauma, cirugía, infección aguda, aspiración de cuerpo extraño ni ejercicio intenso con Vasalva. Conclusiones: La irritación del tercio distal del esófago produjo los episodios graves y persistentes de hipo que incrementaron la presión intratorácica, que a su vez por efecto Macklin, desencadenó el neumomediastino. El diagnóstico se realiza con estudios de imagen. El tratamiento es conservador, con resolución del cuadro clínico entre 5 y 7 días después de la hospitalización.

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Resumen Introducción: El neumomediastino se define como la presencia de aire o gas dentro de los planos fasciales del mediastino. Por lo general, es un fenómeno secundario a perforaciones traumáticas del tracto aerodigestivo. El neumomediastino secundario a una fractura orbitaria es un evento raro. Se asocia a complicaciones potencialmente mortales como el neumotórax, el neumopericardio y la mediastinitis. Objetivo: Describir un caso de neumomediastino secundario a una fractura aislada de piso orbitario y su manejo médico-quirúrgico. Caso clínico: Paciente de sexo femenino de 42 años que sufre traumatismo en regiones facial, cervical y torácica desarrollando secundariamente un enfisema subcutáneo panfacial y un neumomediastino, el cual se resuelve exitosamente. Discusión: El neumomediastino secundario a una fractura aislada de piso orbitario es un evento muy raro. El aire puede descender a lo largo de los espacios fasciales hasta el mediastino. En este sentido, sonarse la nariz es un factor de riesgo para desarrollar esta pa-tología. Conclusión: Ocurrido un trauma maxilofacial puede presentarse enfisemas de espacios profundos de la cabeza, cuello e incluso el mediastino.

Introduction: Pneumomediastinum is defined as the presence of air or gas within the fascial planes of the mediastinum. It is usually a phenomenon secondary to traumatic perforations of the aerodigestive tract. Pneumomediastinum secondary to an orbital fracture is a rare event. And it is related to life-threatening complications such as pneumothorax, pneumopericardium and mediastinitis. Aim: To describe a case of pneumomediastinum secondary to an isolated orbital floor fracture and its medical-surgical management. Clinical case: A 42-year-old female patient who suffers trauma to the facial, cervical and thoracic regions, secondary development of a subcutaneous panfacial emphysema and pneumomediastinum, which resolves successfully. Discussion: Pneumomediastinum following an isolated orbital floor fracture is a very rare event. The air can descend along the fascial spaces to the mediastinum. In this sense, blowing your nose is a risk factor to develop this pathology. Conclusion: After a maxillofacial trauma, emphysema of the deep spaces of the head, neck and even the mediastinum can occur

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BACKGROUND: Spontaneous pneumomediastinum most relevant triggering events are cough, vomiting, nutritional problems, physical activity and use of inhaled drugs. Association of spontaneous pneumomediastinum with non-asthma-related bronchospasm is an infrequent event. CLINICAL CASE: This is the case of a 21-year-old woman without personal or family history of asthma, allergic rhinitis or atopy who during late puerperium had 39 °C fever, paroxysmal cough and chest oppression of sudden onset, as well as wheezing and subcutaneous emphysema of the neck; she had no previous nasal symptoms. Chest X-ray revealed free air in the mediastinum and left lateral side of the neck. Possible cause of the condition was attributed to bronchospasm related to airway infection. Treatment was based on bronchodilators, systemic steroids and supplementary oxygen administration. The symptoms subsided after 48 hours. CONCLUSIONS: In the clinical case herein presented, spontaneous pneumomediastinum precipitating factor appeared to be paroxysmal cough associated with bronchospasm and, hence, we suggest for this entity to be suspected in patients even if there is no previous history of asthma.

Antecedentes: Los desencadenantes del neumomediastino espontáneo de mayor relevancia son tos, vómito, problemas de alimentación, actividad física y el uso de drogas inhaladas. La asociación de neumomediastino espontáneo con broncoespasmo no relacionado con asma es un suceso inusitado. Caso clínico: Mujer de 21 años de edad sin antecedentes personales ni familiares de asma, rinitis alérgica o atopia, quien durante la etapa del puerperio tardío presentó súbitamente fiebre de 39 °C, disnea, tos paroxística y opresión torácica, así como sibilancias y enfisema subcutáneo en el cuello; no presentó síntomas nasales previos. La radiografía de tórax evidenció aire libre en mediastino y cara lateral izquierda del cuello. La posible causa del cuadro se atribuyó al broncoespasmo relacionado con infección de las vías respiratorias. El tratamiento consistió en la administración de broncodilatadores, esteroides sistémicos, antibióticos y oxígeno suplementario. La sintomatología remitió después de 48 horas. Conclusión: En el caso clínico descrito, al parecer el factor precipitante del neumomediastino espontáneo fue la tos paroxística asociada con el broncoespasmo, de tal forma que sugerimos se sospeche en los pacientes aun cuando no existan antecedentes de asma.

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OBJECTIVE:: To characterize clinically all of the patients with spontaneous pneumomediastinum (SPM) admitted to an adult pulmonology ward in Lisbon, Portugal. METHODS:: This was a retrospective descriptive study of all adult patients (≥ 18 years of age) diagnosed with SPM between January of 2004 and September of 2015. RESULTS:: At least one predisposing factor was identified in most (88.9%) of the 18 patients who presented with SPM during the study period. With regard to precipitating factors, bouts of cough were present in 50.0% of the patients. Other precipitating factors included a sudden increase in tobacco consumption, inhaled drug use, occupational inhalation of varnish fumes, intense exercise, and vomiting. The most common complaints were dyspnea (in 83.3%) and chest pain (in 77.8%). Other complaints included cough, neck pain, dysphagia, and odynophagia. Subcutaneous emphysema was found in most of the patients. The diagnosis of SPM was based on chest X-ray findings in 61.1% of the patients. CONCLUSIONS:: Although SPM is a rare condition, it should be considered in the differential diagnosis of chest pain and dyspnea. It can develop without a triggering event or conclusive findings on a chest X-ray, which is usually sufficient for diagnosis. OBJETIVO:: Caracterizar clinicamente todos os pacientes com pneumomediastino espontâneo (PME) admitidos em uma enfermaria de pneumologia para adultos em Lisboa, Portugal. MÉTODOS:: Estudo descritivo retrospectivo no qual foram analisados todos os pacientes adultos (≥ 18 anos de idade) com diagnóstico de PME entre janeiro de 2004 e setembro de 2015. RESULTADOS:: Pelo menos um fator predisponente foi identificado na maioria (isto é, em 88,9%) dos 18 pacientes que apresentaram PME durante o período de estudo. No tocante a fatores precipitantes, crises de tosse ocorreram em 50,0% dos pacientes. Outros fatores precipitantes foram um aumento repentino do consumo de tabaco, uso de drogas inalatórias, inalação ocupacional de vapores de vernizes, exercício intenso e vômitos. As queixas mais comuns foram dispneia (em 83,3%) e dor torácica (em 77,8%). Outras queixas foram tosse, cervicalgia, disfagia e odinofagia. Constatou-se a presença de enfisema subcutâneo na maioria dos pacientes. O diagnóstico de PME baseou-se na radiografia de tórax em 61,1% dos pacientes. CONCLUSÕES:: Embora seja uma doença rara, o PME deve ser levado em conta no diagnóstico diferencial de dor torácica e dispneia. O PME pode surgir sem um evento desencadeante e sem achados conclusivos na radiografia de tórax, que é geralmente suficiente para o diagnóstico.

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ABSTRACT Objective: To characterize clinically all of the patients with spontaneous pneumomediastinum (SPM) admitted to an adult pulmonology ward in Lisbon, Portugal. Methods: This was a retrospective descriptive study of all adult patients (≥ 18 years of age) diagnosed with SPM between January of 2004 and September of 2015. Results: At least one predisposing factor was identified in most (88.9%) of the 18 patients who presented with SPM during the study period. With regard to precipitating factors, bouts of cough were present in 50.0% of the patients. Other precipitating factors included a sudden increase in tobacco consumption, inhaled drug use, occupational inhalation of varnish fumes, intense exercise, and vomiting. The most common complaints were dyspnea (in 83.3%) and chest pain (in 77.8%). Other complaints included cough, neck pain, dysphagia, and odynophagia. Subcutaneous emphysema was found in most of the patients. The diagnosis of SPM was based on chest X-ray findings in 61.1% of the patients. Conclusions: Although SPM is a rare condition, it should be considered in the differential diagnosis of chest pain and dyspnea. It can develop without a triggering event or conclusive findings on a chest X-ray, which is usually sufficient for diagnosis.

RESUMO Objetivo: Caracterizar clinicamente todos os pacientes com pneumomediastino espontâneo (PME) admitidos em uma enfermaria de pneumologia para adultos em Lisboa, Portugal. Métodos: Estudo descritivo retrospectivo no qual foram analisados todos os pacientes adultos (≥ 18 anos de idade) com diagnóstico de PME entre janeiro de 2004 e setembro de 2015. Resultados: Pelo menos um fator predisponente foi identificado na maioria (isto é, em 88,9%) dos 18 pacientes que apresentaram PME durante o período de estudo. No tocante a fatores precipitantes, crises de tosse ocorreram em 50,0% dos pacientes. Outros fatores precipitantes foram um aumento repentino do consumo de tabaco, uso de drogas inalatórias, inalação ocupacional de vapores de vernizes, exercício intenso e vômitos. As queixas mais comuns foram dispneia (em 83,3%) e dor torácica (em 77,8%). Outras queixas foram tosse, cervicalgia, disfagia e odinofagia. Constatou-se a presença de enfisema subcutâneo na maioria dos pacientes. O diagnóstico de PME baseou-se na radiografia de tórax em 61,1% dos pacientes. Conclusões: Embora seja uma doença rara, o PME deve ser levado em conta no diagnóstico diferencial de dor torácica e dispneia. O PME pode surgir sem um evento desencadeante e sem achados conclusivos na radiografia de tórax, que é geralmente suficiente para o diagnóstico.

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