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A 54-year-old woman underwent retroperitoneal laparoscopic nephrectomy for a non-functional left kidney due to ureter stone in September 2022. She was operated without problems. Seven hours postoperatively, she complained of chest pain with a distressed facial expression. Electrocardiogram findings were negative for coronary artery disease, and echocardiography was negative for major pulmonary thromboembolism. Computed tomography showed emphysema and pneumomediastinum. The chest pain gradually resolved over time and was eventually diagnosed with pain due to pneumomediastinum. The subsequent clinical course was uneventful and she was discharged without complications on the 10th postoperative day.

A 47-year-old man was admitted to the emergency room, half a day after having fallen down on his right cheek drunkenly onto a concrete block. Physical examination revealed that the contusion was limited to the right side of his face, only around the cheek, without trauma to the neck, chest or abdomen. But wide ranging tactile crepitus with severe swelling was present on his face and neck due to widely spread emphysema. Computed tomography (CT) scan revealed some fractures of maxillary antrum, facial and cervical emphysema spreading to the lower part of mediastinum. After a conservative treatment, he recovered without any severe systematic complication. It was found that the facial and cervical emphysema and pneumomediastimum completely disappeared on the follow-up CT scan, 18 days after the event.

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

Background: Retroperitoneal laparoscopic surgery has recently become a common procedure for urological fields. We investigated the incidence of respiratory complications and their background during retroperitoneal laparoscopic surgical procedures performed in the kidney position., Methods: We prospectively enrolled 51 patients undergoing urological retroperitoneal laparoscopic surgery, and assessed perioperative respiratory complications using postoperative chest x-ray (CXR) and physical examinations., Results: CXR revealed abnormalities in 32 patients (63%), including atelectasis in 22 (43%), pneumomediastinum in 8 (16%), and subcutaneous emphysema in 4 (8%). All of the atelectasis cases occurred in a middle or inferior robe, or a lingular segment of the lower lung in the lateral decubitus position. Furthermore, atelectasis occurred chiefly in older patients or in those who underwent right side surgical procedures, while pneumomediastinum was more common in left side procedures. One case was switched to an open laparotomy procedure because of possible pneumothorax; however, postoperative respiratory status was stable in all patients., Conclusions: Respiratory complications, such as atelectasis or pneumomediastinum, occurred in more than half of the patients after urological retroperitoneal laparoscopic surgical procedures in the kidney position. Careful perioperative management and postoperative CXR examinations are essential for early detection of such potentially life-threatening complications.

A 57-year-old man was accidentally hit by concrete blocks weighing 3 tons on his right side, and was admitted to a hospital. The radiologic findings taken immediately after trauma demonstrated pneumo-mediastinum, subcutaneous emphysema with multiple rib fractures and right clavicle fracture. At computed tomography (CT) scan 16 hours after trauma, pneumomediastinum and subcutaneous emphysema turned out to be worsened with an increased bilateral pleural effusion. An emergency thoracotomy revealed no abnormalities of trachea or esophagus, and neither bronchoscopy or esophagogastroscopy, showed injuries anywhere inside. The chest cavities and mediastinum were washed well with 3 liters of saline solution. The patient had a good course after surgery without any complications, and was discharged at the 18th hospital day. Mediastinal drainage by an emergency operation should always be a choice to a patient having a progressively worsening pneumomediastinum which might cause tachycardia, low blood pressure, and severe dyspnea due to compression of blood vessels and trachea.

A 19-year-old man consulted a doctor for swelling of his neck and shortness of breath. The day before, he woke up with a slight cough and upper chest pain early in the morning. He went to school and spent the day as usual. He did not have a history of asthma or violent cough. The next day, chest radiography showed subcutaneous emphysema and pneumomediastinum. Computed tomography not only confirmed the presence of mediastinal and subcutaneous air, but also demonstrated a linear radiolucent stripe in the spinal canal corresponding to epidural emphysema. The patient did not have any neurologic findings. His general condition remained good except that his arterial blood oxygen saturation slightly decreased to 95%. Laboratory data were normal, except for serum IgE, which was elevated (2072 IU/ml). He stayed at rest and was treated conservatively and his symptoms improved within a few days. Seven days later, the intraspinal air and pneumomediastinum had resolved spontaneously on follow-up chest computed tomography (CT).

We encountered 3 patients with spontaneous pneumomediastinum. The patients were a 14-year-old female, a 16-year-old male and an 18-year-old male. All 3 were previously healthy. They complained of chest pain or dyspnea. On admission, physical examination revealed subcutaneous emphysema. Chest computed tomography (CT) revealed pneumomediastinum and subcutaneous emphysema. All patients were treated with rest and all recovered in 7 to 9 days without any complication. Spontaneous pneumomediastinum is an uncommon, usually benign, self-limited disorder that usually occurs in young adults without any apparent precipitating factor or disease. Most patients require only conservative treatment.

We encountered 3 male patients with spontaneous pneumomediastinum. The patients were a 16-year old and a 17-year old and a 24-year old. Predisposing episodes for the development of spontaneous pneumomediastinum could be identified in all 3 patients: throwing a ball during a baseball game in 1, lifting a heavy load during work in 2. However, they were healthy and suddenly developed symptoms in the absence of any underlying disease. The presenting complaint was chest pain in all 3 patients. Chest X-ray films and chest CT images revealed pneumomediastinum. A diagnosis of spontaneous pneumomediastinum was made based on chest X-ray films and chest CT images. After conservative treatment, all 3 patients recovered.

A 19-year-old man was punched on the back, and anterior chest pain appeared about 3 hours after injury. The patient was consulted a physician complaining of anterior chest pain. On chest X-ray, mediastinal emphysema was suspected, and transferred to our hospital. Chest computed tomography (CT) revealed mediastinal emphysema. On esophageal radiography and bronchofiberscopy, no abnormal findings were detected. Conservative therapy was conducted, and symptoms had gradually improved. On the 8th hospital day, mediastinal emphysema was improved on chest CT. The patient was discharged on the 10th hospital day. The most frequent cause of mediastinal emphysema after trauma is traffic or downfall accident, and no report on this condition after the punch on the back was found.

Two cases of spontaneous pneumomediastinum caused by vocal exercise were reported. Two 18-year-old men were admitted to our hospital simultaneously in April 2003, because of cervical discomfort and chest pain after vocal exercise of self introduction as a event of freshman in their college. Their chest X-ray film and chest computed tomography (CT) demonstrated typical pneumomediastinum. One of them also showed thoracic epidural emphysema without any particular neurological deficit. Both cases completely recovered by only conservative therapy within 5 days. Spontaneous pneumomediastinum which occurs frequently in young men is thought to be a relatively rare disease showing a good prognosis. It seems important to consider this rare condition when the young man complaints chest pain and discomfort around their neck. We thought that there must be a high possibility of this disease being overlooked as a mere chest pain in young man of unknown reason until now. It is our conclusion that spontaneous pneumomediastinum is a really benign condition that requires no specific examination nor therapy.

A 17 year-old youth presented with swelling of both sides of neck after a fight with a friend. He had been sick with an upper respiratory tract infection for a few days with frequent coughing. Chest radiography showed subcutaneous and mediastinal emphysema. Neck CT at the level of C7 showed air around the trachea, extending to the subcutaneous tissue and the epidural space through the intervertebral foramen. His height was 180 cm and his weight 55 kg, and he had a 181 cm arm span. He had scoliosis and arachnodactyly, and ultrasonic cardiography demonstrated mitral and tricuspid regurgitation. These findings agreed partially with the clinical criteria of Marfan syndrome. Thus, forme fruste of Marfan syndrome was suspected. A rapid rise of airway pressure induced by a coughing attack and loud shouting during the fight probably caused the laceration of the connective tissue in the airway, resulting in mediastinal and epidural emphysema. In this case report, CT at the C7 level satisfactorily identified air in the mediastinum extending to the epidural space through intervertebral foramen.

A 20-year-old woman initially presented with edematous erythema in the upper eyelids in December 1995. She was admitted to our department in January 1996 because of fever and multiple arthralgia. She was given a diagnosis of dermatomyositis (DM) on the basis of characteristic eruption, elevated serum level of creatine kinase, and increased inflammatory reaction. Chest computed tomography (CT) revealed faint interstitial changes in the left lower lung. The administration of corticosteroid caused improvement in the patient's condition and the interstitial lesion in the lung. Although she was asymptomatic, chest CT showed pneumomediastinum in the pretracheal space and concomitant pneumothorax around left bronchus. Those changes spontaneously disappeared 4 weeks later without treatment. The occurrence of pneumomediastinum in patients with DM has been well documented as an indicator of poor prognosis in the literature. It seems that a severe pulmonary disorder could secondary cause pneumomediastinum. In our case, however, the pneumomediastinum developed in spite of the low grade severity of the pulmonary lesion. This finding suggested that the pneumomediastinum may be associated with the development of DM itself.

An 18-year-old man had bronchial asthma and a pneumomediastinum. A computed tomographic scan of the chest revealed the pneumomediastinum, intrapulmonary laceration of the S1b, and a small amount of air in the perivascular space from V1a to V1. Increased pressure in intrapulmonary airways may have resulted in ruptured S1b alveoli and air leakage into the interstitium between the surrounding secondary lobules. The air may have moved along the perivascular space (pulmonary vein) toward the hilum, and eventually into the mediastinum. We know of no previous report of pneumomediastinum in which images of intrapulmonary lesions are presented. In this case computed tomography revealed the mechanism by which the pneumomediastinum probably developed.

We encountered three patients with spontaneous pneumomediastinum. All three (two men and one woman) were previously healthy. They complained of chest pain or dyspnea. On admission, physical examination revealed subcutaneous emphysema. Chest roentgenograms and computed tomograms revealed pneumomediastinum and subcutaneous emphysema. All other findings were normal. All patients were treated with bed rest and all recovered in 7 to 9 days. Pneumomediastinum recurred in one patient after 20 months.

A 20-year-old female developed dysphagia, chest pain and numbness of the left arm after dinner on August 22, 1990. She consulted a doctor, who diagnosed tachycardia and prescribed propranolol. On August 23, she hadn't improved. On the same day, she visited our hospital. Chest X-ray films revealed lucent band and distinct line running parallel to the border of the heart and we suspected mediastinal emphysema. Immediately we took chest CT scan, which demonstrated free air surrounding the trachea, thoracic aorta and heart. We diagnosed spontaneous mediastinal emphysema. She was treated with bed rest and mediastinal emphysema subsided within 8 days. The numbness in the patient's arm is an unusual symptom in mediastinal emphysema. We suggest that the numbness of the arm may be due to interference with the circulation to the arm by distention of the mediastinal tissue.

A case of idiopathic interstitial pneumonia (IIP) with pneumothorax and pneumomediastinum was presented. A 52-year-old male was admitted with the complaint of cough, fever and dyspnea. Chest roentgenogram revealed bilateral reticulonodular shadow and right pneumothorax. Radiological, laboratory and clinical findings were consistent with the diagnosis of acute exacerbation of IIP. Repeated chest CTs showed diffuse interstitial opacities and the presence of pneumothorax and pneumomediastinum. Furthermore, honeycombing and bullous change progressed markedly for two months. The mechanisms of pneumothorax and pneumomediastinum were speculated to be due to the rupture of those cystic lesions which had grown rapidly on follow-up CTs. It was suggested that the formation of honeycombing occurred within a few months and the increasing of honeycombing might be accompanied by so-called acute exacerbation of IIP. We propose that follow-up CTs were useful for the chronological study for interstitial lesions of IIP.

A 67-year-old woman was admitted to our hospital with chest pain and dyspnea which occurred suddenly after vomiting. She was well until admission except for cholelithiasis and hypertension which had been pointed out 3 years earlier. Arterial blood gas analysis showed hypoxemia without hypercapnea. Chest X-ray examination on admission revealed intra-mediastinal air with a niveau behind the heart which compressed the vasculature of the left lower lobe and a small amount of air in the regions adjacent to the trachea, left main bronchus and aortic arch. The serial chest radiographs showed pneumomediastinum, subcutaneous emphysema, pneumothorax and pleural effusion in that order within 16 hours after the onset. The diagnosis of esophageal rupture was made by CT scan of the chest performed after oral administration of Gastrografin, which demonstrated extravasation of contrast medium into the mediastinum. Surgical treatment including eversion stripping and esophagogastrostomy was performed 23 hours after the onset. Pathological examination of the removed specimens revealed a rupture of the lower portion of the esophagus originated in the gastric ulcer of the cardia. In spite of intensive care, she died 45 days after surgery because of renal failure. It was considered that the most important point in the early diagnosis of esophageal rupture was to suspect this disease based on the gastric symptoms followed by the respiratory symptoms and to demonstrate pneumomediastinum in chest X-ray. Chest CT scan performed after the oral administration of contrast medium could be an useful and non-invasive diagnostic procedure.

We report two cases of spontaneous pneumomediastinum. Both were young males, and had no causal diseases or apparent precipitating episodes. Both recovered rapidly with bed rest only. Symptoms, signs, radiological diagnosis, and pathogenesis of pneumomediastinum are discussed.