PNEUMOMEDIASTINUM

LEARNING RADIOLOGY.COM
 Air in the mediastinal space
o Most common in infants
o Rare in adults
 Result of trauma
 Rupture of esophagus
 Rupture of airways
 Air in mediastinum originates from
o Lung
 Most common mechanism in neonates and adults
 Begins with rupture of alveolus
o Usually from increased intraparenchymal pressure
 Air dissects back along perivascular sheaths to hilum and
mediastinum
 Air from ruptured bleb can also extend peripherally into pleural space
 Pneumothorax
 Most instances can be related to sudden rise in intrapulmonary pressure
 Asthma
 Vomiting
 Valsalva maneuver
 Artificial ventilation
 Closed chest trauma
 Sudden drop in atmospheric pressure
o Mediastinal airways
 Rupture of trachea or mainstem bronchus
 Usually produced by accidental trauma
o Esophagus
 Rupture of the esophagus – Boerhaave’s Syndrome
 Can occur with
 Vomiting
 Labor
 Severe asthmatic attacks
 Strenuous exercise (each of these can produce
pneumomediastinum without rupturing the esophagus)
 Site of perforation
o Left, posterolateral wall, distal 8 cm
 Imaging findings
 Combination of pneumomediastinum and left pleural effusion is
very suggestive
 “Continuous diaphragm sign” of pneumomediastinum
 Blue arrow points to "continuous diaphragm sign." The entire diaphragm is visualized from one side to the other
because air in the mediastinum outlines the central portion which is usually obscured by the heart and mediastinal
soft
tissue structures that are in contact with the diaphragm. The red arrow points to the air beneath and posterior to
the heart.
 Symptoms
 Infants
o None
 Adults
o Chest pain (retrosternal) radiating down both arms aggravated by respiration and
swallowing
o Neck
 Trauma to the neck
 Air can track down onto mediastinum
 Imaging findings
o Linear density parallel to heart border
 Separated from heart by air
o Also ring lucency around aorta or pulmonary artery
 “Ring around the artery” sign
o Dissection of air into neck is much less common in infants than adults
o Dissection into chest wall much less common in neonates than older
o Air can outline the central portion of the diaphragm
o “Continuous diaphragm sign”
 Clinical Findings
o Abrupt onset of retrosternal pain
 Usually preceded by episode of vomiting
 Pain is worse on inspiration
 Dyspnea could be severe
o Hamman’s sign – crunching sound heard over the apex of the heart with cardiac
cycle
RADIOPAEDIA.COM

Pneumomediastinum is the presence of extraluminal gas within the mediastinum. Gas may
originate from the lungs, trachea, central bronchi, oesophagus, and track from the mediastinum
to the neck or abdomen.

Pathology

Aetiology

 blunt or penetrating chest trauma

 secondary to thoracic, neck or retroperitoneal surgery
 oesophageal perforation
o Boerhaave syndrome
o endoscopic intervention
o oesophageal carcinoma
 tracheobronchial perforation
o laceration
o bronchial stump dehiscence
o bronchoscopy
o tracheostomy
o laryngeal fracture
 vigorous exercise (see: pulmonary interstitial emphysema)
o childbirth (see: Hamman's syndrome)
o weightlifting
o Valsalva maneuver
 asthma
 barotrauma
o diving
o ventilator - most commonly secondary to ARDS with positive pressure ventilation
 infection
o tuberculosis
o histoplasmosis
o dental or retropharyngeal infection
o mediastinitis
 idiopathic

Radiographic features

Small amounts of air appear as linear or curvilinear lucencies outlining mediastinal contours
such as:

 subcutaneous emphysema
 elevated thymus - thymic wing sign
 air anterior to pericardium - pneumopericardium
 air around pulmonary artery and main branches - ring around artery sign
  air outlining major aortic branches - tubular artery sign
 air outlining bronchial wall - double bronchial wall sign
 continuous diaphragm sign - due to air trapped posterior to pericardium
 air between parietal pleura and diaphragm - extrapleural sign
 air in pulmonary ligament
 Naclerios V sign

Differential diagnosis

Must be distinguished most importantly from:

 medial pneumothorax
 pneumopericardium
 Mach bands
 subcutaneous emphysema

For small air collections on a CT scan, also consider:

 subcarinal air cyst 3

 paratracheal air cyst 3

Pneumoperitoneum
DIFFRENETIAL DIAGNOSE :

Pneumopericardium represents air within the pericardium, thus surrounding the heart.

Underlying causes include:

 thoracic surgery / pericardial fluid drainage

 penetrating trauma
 blunt trauma (rare)
 infectious peticarditis with gas-producing organisms
 fistula
o between the pericardium and an adjacent air-containing organ (i.e. stomach or
esophagus))

Radiographic features

Plain film and CT

On both plain films and CT appearances are characteristic, the heart being partially or
completely surrounded by air, with the pericardium sharply outlined by air density on either side.

Complications

 cardiac tamponade

Differential diagnosis

A pneumopericardium can usually be distinguished from pneumomediastinum, since air in the

pericardial sac should not rise above the anatomic limits of the pericardial reflection on the
proximal great vascular pedicle. Also on radiographs obtained with the patient in the decubitus
position, air in the pericardial sac will shift immediately, while air in the mediastinum will not
shift in a short interval between films.

Occasionally, it may not be possible to distinguish pneumopenicardium from

pneumomediastinum on plain film.
The extrapleural air sign is one of the many signs of pneumomediastinum, and was first described by
Lillard and Allen in 1965. It is defined as the presence the air between the parietal pleura and
the diaphragm. On a lateral projection the air forms a radiolucent pocket of air posterior to the dome of
the hemidiaphragm. The reader should be aware that this term is not synonymous with the
term extrapleural sign by itself.

Naclerio V sign is a sign described on the plain film in patients with

a pneumomediastinum occurring often secondary to an oesophageal rupture.
It is seen as a V-shaped air collection. One limb of the V is produced by mediastinal air outlining
the left lower lateral mediastinal border. The other limb is produced by air between the parietal
pleura and medial left hemidiaphragm.
Although Naclerio V sign was originally described in patients with oesophageal
rupture, it is not entirely specific to that condition.
Subcarinal air cysts refer to small air cyst that can be detected on a CT scan. They are thought
to represent small main bronchial diverticula although the former term is preferred 2. They
may be associated with chronic airflow limitation.
Clinical presenation
Patients are asymptomatic and there are often seen on imaging for some other reason.
Radiographic features
HRCT - CT chest
They typically have a lobulated margin and can demonstrate ductlike communications between
the air cyst and bronchi. Ductlike communications can arise from the posterointerior aspect of
the proximal side of main bronchi; They can be either solitary or multiple. The larger subcarinal
air cysts tends to be multiloculated.
Differential diagnosis
If there are relevant clinical factors, consider
 a small pneumomediastinum
A male infant was born at 40 weeks of gestation by vacuum-assisted vaginal delivery. Mild respiratory
distress with expiratory grunting and subcostal retraction was noted 1 hour after birth. Arterial oxygen
saturation remained at more than 95% without the administration of supplemental oxygen. Chest
radiography performed 6 hours after birth (Panel A) showed the spinnaker-sail sign, consisting of a large,
wedge-shaped opacity extending from the right hemidiaphragm to the superior mediastinum (white
arrows), representing thymic tissue displaced from its usual location by a collection of gas under
pressure (black arrows). Axial computed tomography of the chest revealed air trapped between the
pericardial sac and the thymus, confirming a diagnosis of anterior pneumomediastinum (Panel B, arrow).
Named for its visual resemblance to the headsail of a boat, the spinnaker-sail sign occurs with a
spontaneous anterior pneumomediastinum and usually resolves without specific treatment. After being
observed for clinical and radiographic improvement for 3 weeks, the infant was discharged home in
good condition.

Spinnaker Sail Sign-abnormal elevation of lobes of the thymus seen with pneumomediastinum;
thymic sail sign is normal
Area of interest :
unknown
Imaging Technique:
Day 2 chest radiographs,Day 2 chest radiographs
A P-A chest radiograph showing gas outlining the inner surface of the mediastinal pleura, which
depicts the aortic knob, the left border of the heart (indicated by black arrows) and the superior
vena cava (indicated by a black arrowhead). Note the presence of air surrounding the
brachiocephalic vessels “ tubular vessel sign” (indicated by white arrowheads).

http://www.eurorad.org/eurorad/view_figure.php?pubid=2490&figid=4897&nr=1
A P-A chest radiograph showing the mediastinal air lifting the mediastinal pleura off the descending
aorta (indicated by a gray arrow). A linear band of air parallels the other border of the descending aorta
(indicated by a gray arrowhead). Linear streaks of air surround the left main bronchus “double bronchial
wall sign” (indicated by a white arrowhead). All the extent of the left hemidiaphragm is visible. The
“continuous diaphragm sign” (indicated by two black arrows) is seen.
http://www.eurorad.org/eurorad/view_figure.php?pubid=2490&figid=4897&nr=1

Mach Effect :
An optical effect at the margin between areas of slightly different density.
In this image mimics a pneumo-mediastinum .
Ring-Around-the-Artery Sign-air surrounding right pulmonary artery on lateral chest from
pneumomediastinum

Fig 1: Chest x ray PA view showing left sided pneumothorax (star) with continuous diaphragm sign (thin
black arrows) suggestive of pneumomediastinum