What is the treatment for pneumo-mediastinum?

Treatment of Pneumomediastinum

Conservative management is the recommended treatment for spontaneous pneumomediastinum, consisting of bed rest, oxygen therapy, and analgesics, as this approach leads to rapid resolution in most cases. 1

Diagnosis and Assessment

• Pneumomediastinum is characterized by the presence of free air in the mediastinal structures
• Common symptoms include:
  • Retrosternal chest pain (most common)
  • Neck swelling/subcutaneous emphysema
  • Dyspnea
  • Rhinolalia (nasal speech)
• Diagnostic workup:
  • Chest radiography (diagnostic in most cases)
  • CT scan for confirmation when needed
  • Esophagogram to exclude esophageal rupture (essential)
  • Cardiologic examination to exclude pericarditis

Treatment Approach

Conservative Management (First-line)

For spontaneous pneumomediastinum without complications:

1. Bed rest/activity restriction
2. Supplemental oxygen therapy
3. Analgesics for pain control
4. Clinical monitoring
5. Prophylactic antibiotics may be considered (though evidence for this is limited) 2

The mean hospital stay typically ranges from 3-10 days 1, with complete resolution occurring within this timeframe in most cases.

Specific Interventions for Complicated Cases

• For severe subcutaneous emphysema: Subcutaneous air drainage may be required 3
• For pneumomediastinum with pulmonary vessel obstruction: Intravascular stents may be considered 4
• For cases where clinical findings cannot differentiate mediastinal fibrosis from mediastinal granuloma: Itraconazole (200 mg once or twice daily for 12 weeks) may be considered 4

Special Considerations

• Traumatic pneumomediastinum and those with identified causes (like esophageal perforation) require specific treatment of the underlying cause
• Surgical intervention is generally not needed for spontaneous pneumomediastinum 3
• Complications such as tension pneumomediastinum and tension pneumothorax are rare but should be monitored for

Prognosis

Spontaneous pneumomediastinum is generally a benign, self-limiting condition with excellent prognosis. In long-term follow-up (3-12 years), recurrence is rare, with only 1 recurrence observed in a study of 22 patients 1.

Important Caveats

• Always exclude potentially life-threatening conditions such as esophageal perforation or necrotizing mediastinitis before diagnosing spontaneous pneumomediastinum
• Conservative treatment is effective regardless of the severity of pneumomediastinum 2
• No evidence supports that more aggressive interventions improve outcomes in uncomplicated cases