What is the best test to evaluate the esophagus in a pediatric patient with pneumomediastinum?

From the Guidelines

In a pediatric patient with pneumomediastinum, the best test to evaluate the esophagus is a contrast-enhanced CT scan or CT esophagography to assess for esophageal perforation or rupture 1.

Alternative Options

• Alternatively, a contrast-enhanced esophagogram (gastrografin) may provide useful information regarding the location and the contained character of the esophageal injury 1.
• If there is a high suspicion of esophageal injury, an esophagoscopy may be necessary to directly visualize the esophageal mucosa, especially in the pediatric population where endoscopy is the upfront evaluation examination 1.

Important Considerations

• It is essential to avoid using barium as a contrast agent in this scenario due to the risk of barium extravasation into the mediastinum, which can lead to mediastinitis.
• CT scan is highly sensitive (92–100%) in detecting esophageal perforation and helps to assess extension to adjacent structures and guide initial therapy 1.
• In pediatric patients, endoscopy remains the upfront evaluation examination as severe injuries are rare and long-term effects of radiation exposure are an important issue 1.

Key Points

• The choice of diagnostic test should be based on the clinical presentation and suspicion of esophageal injury.
• A high degree of suspicion is required at presentation to avoid delay in diagnosis and allow timely management 1.
• The role of emergency endoscopy is currently reduced to situations in which CT cannot be employed, but it remains the main diagnostic tool for esophageal/gastric strictures in symptomatic patients 1.

From the Research

Evaluation of the Esophagus in Pediatric Patients with Pneumomediastinum

• The best test to evaluate the esophagus in a pediatric patient with pneumomediastinum is a topic of debate, with various studies suggesting different approaches 2, 3, 4, 5, 6.
• A study published in 2015 found that a single-contrast water-soluble esophogram alone is sensitive in the diagnosis of esophageal injury or leak, with a 100% sensitivity and negative predictive value 2.
• However, other studies have suggested that esophagrams may not be necessary in pediatric patients with spontaneous pneumomediastinum, as they are rarely associated with esophageal perforation 3, 4, 6.
• A study published in 2023 found that pediatric patients with spontaneous pneumomediastinum benefit from evaluation, management, and treatment based on their presenting symptoms, and that esophagrams do not alter management 3.
• Another study published in 2016 found that all esophagrams in patients with both spontaneous and post-traumatic pneumomediastinum were negative, and that patients were exposed to unnecessary radiation doses during esophagrams 4.
• A study published in 2013 found that fluoroscopic esophagography is unnecessary in patients with pneumomediastinum when CT is negative for esophageal perforation 5.
• A retrospective case-control study published in 2023 found that spontaneous pneumomediastinum is not associated with esophageal perforation, and recommended avoiding CT scans and esophagrams unless there is discrete esophageal concern 6.

Key Findings

• Esophagrams may not be necessary in pediatric patients with spontaneous pneumomediastinum 3, 4, 6.
• A single-contrast water-soluble esophogram alone may be sufficient for diagnosing esophageal injury or leak 2.
• CT scans may be sufficient for evaluating pneumomediastinum, and fluoroscopic esophagography may be unnecessary when CT is negative for esophageal perforation 5.
• Management of spontaneous pneumomediastinum should be guided by symptomatology, rather than routine imaging studies 3, 6.