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[Case Report]

Neck Pain and Dyspnea in a Swimmer

Spontaneous Pneumomediastinum Presentation and Return-to-Play Considerations

Richard T. Ferro, MD; Douglas B. McKeag, MD, MS

American Medical Society for Sports Medicine
Case Report Series Editor: Kimberly G. Harmon, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 10 - OCTOBER 1, 1999


In Brief: Spontaneous pneumomediastinum is usually a benign, self-limiting condition in which retrosternal chest pain is the most common complaint and subcutaneous emphysema is the most prevalent physical finding. Chest radiographs confirm the diagnosis. A case report of a 19-year-old college swimmer who initially reported anterior neck pain demonstrates the importance of avoiding complications such as pneumothorax with careful monitoring, outpatient management, and cessation of athletic activities. After 7 to 10 days patients can slowly resume sports if symptoms do not recur.

Spontaneous pneumomediastinum (SPM) is relatively uncommon, but its occurrence is well documented in athletes. It is often associated with Valsalva's maneuver during sports activities (1,2).

The incidence of SPM has been reported to be as high as 1 in 7,115 emergency room admissions (3,4); however, because healthy young people with SPM often present without severe symptoms or physical exam findings, the incidence is believed to be higher. In the case described below, the paucity of clues in the patient's history and physical examination—coupled with participation in contraindicated athletic activities—may have exacerbated mildly symptomatic SPM.

Case Report

History. A 19-year-old male collegiate swimmer developed mild right-sided neck pain during a strenuous swimming practice that included breath-holding exercises. He said the diffuse, anterior pain did not radiate or interfere with his ability to practice. After the pain worsened and became more anterior during practice the following day, an athletic trainer diagnosed the pain as a "muscle strain" and gave the athlete ibuprofen. Two days later, after his first race at a swim meet, the athlete reported worsening neck pain, shortness of breath, and difficulty swallowing. He was sent to a local hospital emergency department (ED) after the swim meet.

At this point, the patient denied pain radiation to the chest, arm, back, or jaw. He also denied coughing, wheezing, fever, chills, nausea, vomiting, headache, recent illness, history of similar symptoms, and significant medical or surgical history. The patient reported no medication allergies and denied tobacco, alcohol, and illicit drug use.

Physical findings. The athlete appeared anxious, though his vital signs, orthostatic testing, and pulse oximetry were normal. His skin and head, eye, ear, nose, and throat exams were also normal. Examination of his neck revealed discomfort in the right midanterior cervical region, though no swelling, erythema, or obvious deformities were found. His neck was supple with full range of motion. Manual muscle testing was 5/5 bilaterally with no discomfort during resisted motion. His trachea was midline and freely mobile, and his pulses were regular and symmetric.

Differential diagnosis. The differential diagnosis included pulmonary embolism, panic disorder, exercise-induced bronchospasm or asthma, pneumothorax, SPM, cervical or mediastinal tumor, drug abuse, carotid thrombosis, cervical radiculopathy, foreign body aspiration, and esophageal stricture or tear.

Diagnostic tests. The patient's blood work and barium swallow, performed during the ED visit, were normal. Chest and cervical spine radiographs taken that same day were initially read as negative by the ED physician. However, a radiologist who reread these films the following day detected a small amount of free air on the right side of the mediastinum, and the lateral cervical spine radiograph (figure 1) revealed free air tracking up the deep cervical tissues and fascial layers behind the trachea and larynx.

[Figure 1]

Computed tomography (CT), performed 2 days later to determine the cause of the patient's pneumomediastinum and to rule out progression, revealed a small amount of residual air in the deep right cervical tissues, posterolateral to the trachea, at the lung apices (figure 2). No pneumothorax or subpleural blebs were found.

[Figure 2]

Diagnosis. The final diagnosis was SPM.

Treatment. We advised the patient to refrain from swimming for at least 1 week from the onset of symptoms. However, to prepare for an upcoming meet the patient engaged in "light" swim practices 6 days after the onset of symptoms and 2 days after his office visit. Though the patient's neck pain and shortness of breath had improved, his anxiety and dysphagia had worsened slightly. After reexamination, he was withheld from all athletic participation until all symptoms resolved. He returned to activity 1 week later without symptom recurrence.

Discussion

Also known as mediastinal emphysema, SPM is second only to spontaneous pneumothorax as the leading cause for hospitalization in healthy individuals under the age of 30 who experience sudden chest pain or shortness of breath (1,3).

Causes. SPM may be caused by several conditions that allow free air to enter the mediastinal tissues. These include alveolar rupture associated with elevated alveolar pressure from decompression in diving, or after coughing, vomiting, or sudden exertion (2,3,5,6). Complications of free air within mediastinal tissues include pneumothorax (due to the rupture of the mediastinal pleura), tension pneumomediastinum (due to cardiac compression and tamponade), air block (or the splinting action of air in the lung connective tissue that promotes further alveolar hyperinflation), and pulmonary vascular obstruction (5,7,8).

In the present case, SPM was probably caused by the breath-holding exercises during a strenuous swimming workout. Valsalva's maneuver is typically performed during many athletic endeavors. Risk factors to consider include diabetic ketoacidosis, marijuana smoking, anorexia nervosa, bronchial and pulmonary function testing, and the use of illicit drugs such as heroin, cocaine, ecstasy, and speed (2,6,7).

History and physical findings. SPM can have diverse clinical manifestations. Coughing and/or asthma often precede the development of the condition (1,3,4). SPM can be asymptomatic but may cause retrosternal chest pain in up to 88% of patients (1). Other common complaints include dyspnea, neck pain, weakness, dysphagia, sore throat, back pain, shoulder pain, swollen neck, and abdominal pain (1,4).

Physical signs may be absent. However, Abolnik et al (1) reported that subcutaneous emphysema was present in 60% of patients in a study sample. Hamman's sign, also known as mediastinal crunch, is a crunching, rasping, or popping sound heard over the precordium that is synchronous with the heart beat and is sometimes heard at a distance from the chest (9). Once thought to be pathognomonic, Hamman's sign is found in less than half of the cases and was absent in our swimmer (1,2,9). Other nonuniversal physical findings include pulsus paradoxus and decreased heart sounds (1).

Radiographic diagnosis. Chest radiography confirms the diagnosis of SPM—the lateral view is particularly revealing (2). SPM manifests as free air that outlines mediastinal structures and is usually found above the heart on the left. It is important not to confuse SPM with pneumothorax, because the two are associated in up to 18% of patients, and prognosis and treatment will differ (10). Free air is stationary within tissue planes in SPM but is mobile within the pleural space in pneumothorax. In pneumothorax, free air never outlines mediastinal structures, and air contour is modified in lateral decubitus films (2,3,5). In SPM, the pleural line may not form as smooth an arc as in pneumothorax (5). Free air in SPM can be confused with pneumothorax when streaks extend along the diaphragm, over the lung apex, or behind the sternum (5). Thus, obtaining further studies, such as a CT scan, may prove beneficial.

Treatment. Return-to-play determinations are difficult because there are no evidence-based medical guidelines for the treatment of SPM. Some authors state that activity restrictions and avoidance of predisposing factors are unnecessary (1,2,6,10). Others suggest hospital admission because of the potential for complications (7,8). Though hospital admission has been routine, we believe it is probably unnecessary unless SPM is associated with significant complications.

We prefer a less conservative return-to-play approach that involves careful monitoring and outpatient management. As team physicians, we strongly believe it unwise to allow a symptomatic individual to return to play. Because pneumomediastinum has been reported to resolve within 4 to 10 days (1,2,6,7,9,10) and appears to have a low recurrence rate (1 in 14 to 1 in 23 patients) (1,3,6), it seems reasonable to allow an asymptomatic athlete to slowly resume full activity 7 to 10 days after symptoms occur, but only as long as there is no recurrence. Finally, a chest radiograph and CT scan might be considered for follow-up testing to ensure that the patient's condition has fully resolved and to definitively rule out any underlying pathology, when necessary.

References

  1. Abolnik I, Lossos IS, Breuer R: Spontaneous pneumomediastinum: a report of 25 cases. Chest 1991;100(1):93-95
  2. Morgan EJ, Henderson DA: Pneumomediastinum as a complication of athletic competition. Thorax 120211;36(2):155-156
  3. Yellin A, Lidji M, Lieberman Y: Recurrent spontaneous pneumomediastinum: the first reported case, letter. Chest 120213;83(6):935
  4. Munsell WP: Pneumomediastinum: a report of 28 cases and review of the literature. JAMA 1967;202(8):689-693
  5. Bejvan SM, Godwin JD: Pneumomediastinum: old signs and new signs. Am J Roentgenol 1996;166(5):1041-1048
  6. Pittman JA, Pounsford JC: Spontaneous pneumomediastinum and Ecstasy abuse. J Accid Emerg Med 1997;14(5):335-336
  7. Onwudike M: Ecstasy induced retropharyngeal emphysema. J Accid Emerg Med 1996;13(5):359-361
  8. Joshi JM: Spontaneous pneumomediastinum: cause and consequence. J Assoc Physicians India 1996;44(11):829-831
  9. Hamman L: Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1-21
  10. Bouwen L, Bosmans E: Posttraumatic pneumomediastinum: not always cause for alarm. Acta Chir Belg 1997;97(3):145-147

Dr Ferro is an assistant professor of community and family medicine and orthopedic surgery and director of primary care sports medicine at Duke University Medical Center in Durham, North Carolina. He holds a certificate of added qualifications in sports medicine. Dr McKeag is professor and chair of family medicine at Indiana University School of Medicine and director of sports medicine at the National Institute for Fitness and Sport, both in Indianapolis. Dr Harmon is a primary care sports medicine physician at the University of Washington and a clinical instructor in the Department of Family Practice at the University of Washington Medical School, both in Seattle. Address correspondence to Richard T. Ferro, MD, Duke University Medical Center, Division of Family Medicine, Box 3886, Durham, NC 27710; e-mail to [email protected].


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