Hidden Behind the Heart: Retrocardiac

Pneumomediastinum - A Diagnostic and Therapeutic

Challenge
Fathi AR1, Kandiah V1, Ibrahim NH2, Lee SC2, Zarifa Z3, Koay YW4
1
Paediatrics Surgery, Department Of General Surgery, Hospital Tengku Ampuan Afzan, Pahang, Malaysia
2
Department Of Paediatrics, Hospital Tengku Ampuan Afzan, Pahang, Malaysia
3
Department Of Radiology, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia.
4
Paediatrics Surgery, Hospital Tunku Azizah, Kuala Lumpur, Malaysia

Introduction: conservatively with supportive therapy

until the RCPM resolved.
Retrocardiac pneumomediastinum
(RCPM) is a rare air leak characterized by
the presence of interstitial air in the
mediastinum, specifically occurring
posterior to the heart in this case. We
present a case of RCPM in a preterm infant
born at 28 weeks' gestation who required
mechanical ventilation with high-
frequency oscillatory ventilation (HFOV)
and multiple surfactant administrations.

Case Presentation:

A male infant born at 28 weeks' gestation

had been intubated since birth and was
ventilated with HFOV for respiratory
distress syndrome (RDS). Three doses of
surfactant were administered. On the third
day of life, a routine chest radiograph
revealed RCPM characterized by
radiolucent streaks that corresponded to the
pericardial silhouette. The infant remained
stable with no respiratory or cardiovascular
compromise and was treated
Retrocardiac pneumomediastinum in 28
week-old intubated patient. Picture above
during incident and picture below after 5
days of conservative management.
Discussion:
Pneumomediastinum is an air leak in the
mediastinum. Macklin and Macklin's
experimental studies provided insights into
its pathophysiology ; alveolar rupture
results from a pressure gradient between
the alveolus and surrounding tissues. It
develops either through overinflation of the
alveolus or by reducing interstitial
pressure. Following leakage into the
interstitial tissue, air diffuses into the
subcutaneous tissue, peribronchial tissue,
and mediastinum. In the lungs, the alveolar
walls remain intact due to pressure
equalization between the affected and
adjacent alveoli.
A newborn's pneumomediastinum affects
2.5 out of every 1000 live births . The
incidence of pneumomediastinum was
demonstrated in 2.3% of regular vaginal
deliveries, 2% of premature infants, 1% of
caesarean sections, and 8% of intubated
neonates, according to the findings of a
study conducted in 1971 by Steele RW and
coworkers. Congenital abnormalities,
intubation, and amniotic fluid stained with
methylene blue were some apparent
predisposing or related variables. Hyaline
membrane illness, caesarean delivery,
small size for age, preterm, or dysmaturity
were not shown to be significantly
correlated.
Radiographically, pneumomediastinum
can manifest in various patterns. A
common depiction is that of a "wind-blown
spinnaker sail," where a lobe or lobes of the
thymus are raised off the heart. This is most
prominently observable in a left lateral
oblique view. Alternatively, a halo
surrounding the heart might be evident in
the anteroposterior projection. It is
imperative to differentiate this from
pneumopericardium, in which air envelops
the heart entirely, extending to the inferior
border.
Pneumomediastinum can be primary or
secondary. Treatment options include
conservative management and surgical
drainage. In this case, a conservative
approach was chosen because of the
fragility and stability of the infant. Most
cases of RCPM resolve spontaneously with
conservative treatment. Surgical drainage
is reserved for cases with significant
respiratory or cardiovascular compromise
or when conservative treatment fails.
Surgical procedures such as
mediastinotomy or thoracotomy aim to
relieve tension caused by air trapping in the
mediastinum.
Conclusion:
RCPM is a rare condition that can occur in
premature infants who are mechanically
ventilated. Early detection and
classification pneumomediastinum is
critical for proper therapy. Close
monitoring and personalised treatment
techniques are required for the best
possible patient outcomes.

Reference:

Rocha G, Guimarães H.(2017)

Spontaneous pneumomediastinum in a
term neonate - case report. Clin Case Rep.
2017 Dec 22;6(2):314-316.

Correia-Pinto, J., and T. Henriques-

Coelho. (2010.) Neonatal spontaneous
pneumomediastinum and te spinnaker sail
sign. N. Engl. J. Med. 363:2145.

Hauri-Hohl A, Baenziger O, Frey B.

(2008) Pneumomediastinum in the
neonatal and paediatric intensive care unit.
Eur J Pediatr. 2008 Apr;167(4):415-8.