CHEST RADIOLOGY


Case 7:

A 20-year old lady presented with a 3-day history of vomiting and cough following social drinking. During one such episode of vomiting, she experienced severe retrosternal pain and dyspnoea. OGD scopy was normal.
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Imaging Findings

Radiographs and CT scan of neck and chest reveal subcutaneous emphysema with pneumomediastinum. Extensive subcutaneous emphysema was noted in the upper chest and neck. In the neck, air caused fascial dissection in both the supra and infra hyoid regions and extended into the prevertebral space from C2 to T4 vertebral levels. Air was also noted extending to the epidural space. No mediastinal collection or features suggestive of mediastinitis was noted on CT.

Diagnosis

Epidural pneumatosis with pneumomediastinum

The patient was treated conservatively with nasogastric feeding and antibiotics during her stay, a repeat CT performed after 4 weeks revealed complete resorption of the epidural air and pneumomediastinum.

Discussion

Epidural pneumatosis following lumbar puncture and epidural analgesia is well recognized. It has also been reported following trauma, strenuous exercise and chest tube placement. Spontaneous pneumomediastinum following cough, vomiting during an asthmatic attack causing epidural pneumatosis are very unusual, though a few cases have been reported.

In most cases, epidural pneumatosis secondary to spontaneous pneumomediastinum is a benign entity that does not cause neurological deficit and should not be a cause of excessive concern. It is only in post-traumatic cases that a dural enteric fistula may be present which could have serious complications.

 

Contribution

Dr. Bhujang Pai, PD Hinduja Hospital, Mumbai