International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 1 , Pages 35-38, January 2008

Subcutaneous emphysema, pneumomediastinum and epidural emphysema in a child due to foreign body aspiration mimicking croup syndrome

Department of Pediatrics, Pediatric Surgery and Radiology, Eskisehir Osmangazi University, Faculty of Medicine, TR-26480, Eskisehir, Turkey

Received 26 May 2006; received in revised form 26 September 2007; accepted 28 September 2007. published online 07 November 2007.

Article Outline

Summary 

Epidural emphysema (pneumorachis) is a rare condition and usually accompanies subcutaneous emphysema or pneumomediastinum. We present a 18-month-old boy with pneumomediastinum, subcutaneous emphysema and epidural emphysema due to foreign body aspiration mimicking croup syndrome. He was admitted to emergency unit with the complaint of respiratory distress and noisy breathing. Physical examinations revealed inspiratory stridor and tachypnea. His clinical status has been worsened in spite of supportive treatment. Computerized thorax tomography showed pneumomediastinum, subcutaneous emphysema at the cervical region and epidural emphysema. A plastic part of toy was removed through a bronchoscope from the trachea and his respiratory distress was completely resolved after bronchoscopy. Children with foreign body aspiration may be admitted to emergency unit with different clinical findings mimicking asthma or respiratory infections. Foreign body aspiration should be considered in children with pneumomediastinum, subcutaneous emphysema or epidural emphysema and diagnostic and also therapeutic bronchoscopy should be done immediately.

Keywords: Epidural emphysema, Subcutaneous emphysema, Pneumomediastinum, Children, Foreign body aspiration, Pneumorachis

 

Back to Article Outline

1. Introduction 

Foreign body aspiration (FBA) is most common accident in children and is one of leading causes of death in children, especially among those younger than 3 years of age [1], [2], [3]. FBA may cause a wide variety of symptoms and may be similar with acute or chronic respiratory system disorders such as asthma, bronchiolitis or laryngotracheobronchitis [1], [2]. FBA and its evolution can lead to complications such as pneumonia, pneumomediastinum, pneumothorax, atelectasis, bronchial stenosis and bronchospasm [1], [3], [4], [5]. Epidural emphysema (pneumorachis) is a rare condition and usually accompanies subcutaneous emphysema or pneumomediastinum and these are rarely reported with FBA [6]. We present a 18-month-old boy with pneumomediastinum, subcutaneous emphysema and epidural emphysema due to FBA.

Back to Article Outline

2. Case report 

A boy aged 18-month-old was admitted to Pediatric Emergency Unit with the complaints of sudden onset respiratory distress which the parents had noticed for a few hours. He has cough that had commenced 14 days before. He has no history of trauma or foreign body aspiration. He has a history of wheezing associated with acute bronchiolitis at 7 months of his age. Physical examination revealed that he was alert, anxious with no cyanosis and he has right-sided otitis media, noisy breathing, inspiratuar stridor and suprasternal retractions without wheezing or rales. He was tachycardic (164/min) and tachypneic (80/min), blood pressure was 95/65mmHg and oxygen saturation was 93% on oxygen mask. Other system examinations were normal. The child's psychomotor development and anthropometric parameters were normal. Oxygen, cool air, dexamethasone had been given because he had inspiratory stridor. He was treated with intravenous ceftriaxone for presumed otitis media. First chest X-ray showed bilateral hyperinflation without emphysema, pneumomediastinum, pneumonia or opacity due to foreign body and lateral cervical graphy was also normal (Fig. 1). By the 4th hour of his intensive care admission, bilateral palpable crepitus was present in the neck and chest X-ray showing striking subcutaneous emphysema in the soft tissues around the cervical region in addition to the hyperinflation bilaterally, in spite of these therapies. By the 12th hour of his admission, his clinical situation worsened and chest X-ray showed bilateral hyperinflation, pneumomediastinum and subcutaneous emphysema at the cervical region (Fig. 2). Clinical findings were unresponsiveness to therapies including steroid, antibiotics, subcutaneous adrenaline injection, oxygen or cool air. A computed thorax tomography confirmed the pneumomediastinum, subcutaneous emphysema in the cervical region and epidural emphysema from cervical region to L2 level (Figs. 3 and 4). Although there was no history of foreign body aspiration and bronchoscopy was performed. The foreign body was removed through a bronchoscope by a pediatric surgeon from the trachea. The parents recognized the plastic object as part of toy gun (Fig. 5). His respiratory distress was completely resolved after bronchoscopy. The 5th day after bronchoscopy, pneumomediastinum and subcutaneous emphysema were recovered. He was discharged after resolution of subcutaneous emphysema, pneumomediastinum and physical findings. A repeat CT scan was not done.

Back to Article Outline

3. Discussion 

Pneumomediastinum and subcutaneous emphysema are defined as the presence of air in the mediastinum and under the skin as the result of on air leak [7]. Pneumomediastinum occur spontaneously during childhood but the most common medical causes were asthma and infections [7], [8]. Other causes are toxic effects, trauma, iatrogenic, diabetes mellitus, leukemia, valsalva's maneuvers due to tissue weakness and rarely FBA [7], [8], [9], [10]. Pneumomediastinum may result from non-penetrating airway obstruction that causes to rise intraalveolar pressure and alveolar rupture [7], [10]. Airway rupture provides an entry for interstitial air to extend along the perivascular sheats towards the mediastinum and out of the subcutaneous tissue. In mediastinum air spreads into loose areolar tissue and can enter into neck and subcutaneous tissue leading to subcutaneous emphysema [4], [7]. Damore and Dayan [8] reported that the prevalence of pneumomediastinum in children with airway foreign bodies is 1%. While spontaneous subcutaneous emphysema and pneumomediastinum are usually self-limited in patients with asthma and bronchiolitis, in the presence of a foreign body, persistence of expiratory outflow resistance and associated coughing leads to progressive course like our case [4], [6], [7]. The degree of respiratory distress depends on the amount of trapped air and may appear clinically as subcutaneous emphysema, dyspnea and chest pain [7]. In our case, pneumomediastinum was not observed at admission. His clinical course was dramatically worsened within hours and, chest X-ray showed pneumomediastinum and subcutaneous emphysema.

Epidural emphysema (pneumorachis) is also a rare condition and usually accompanies with pneumomediastinum, subcutaneous emphysema and pneumothorax [6], [10]. Air enters the epidural space through the fascial planes over the brachial plexus and axillary artery [6]. There have been only a few reports in the literature describing epidural emphysema as nontraumatic causes including anorexia nervosa and asthma and is associated with pneumomediastinum [10], [11], [12], [13]. Tambe et al. [6] reported 12-month-old boy who has epidural emphysema due to FBA like our case. Epidural emphysema due to foreign body aspiration in children has been rarely reported like our case [6]. While the chest X-ray is able to define the presence of a pneumomediastinum and subcutaneous emphysema, the diagnosis of epidural emphysema can only be made by computerized tomography. In our case, the presence of alveolar hyperinflation probably acted as a predisposing factor for the occurrence of pneumomediastinum and epidural emphysema. Thorax tomography demonstrated epidural emphysema from cervical part of the medulla to L2 level without pneumocarnium and he has no neurological symptoms and signs. Epidural emphysema did not require specific treatment and completely resolved over 2–3 weeks [6]. Removal of the foreign body from airway is the main treatment modalities and analgesics, optimal control of underlying conditions and rest are important in preventing progression of respiratory distress.

The location of lodging of the foreign bodies has been shown to be mainly in the right lung and 11.3% in the trachea [1], [3]. Most frequently aspirated objects are food and nonorganic materials such as metals and plastics, rocks, respectively. Toys or parts of toys are 1% of the aspirated objects [14]. The part of plastic toy was removed from trachea as it was located at tracheal level, it rose at high level during expirium but trapped air was not completely removed from the lung. Pneumomediastinum, subcutaneous emphysema and epidural emphysema were observed due to intraalveolar pressure rise. As the foreign body was located at the tracheal level, clinical findings at admission were similar with croup syndrome. Our patient has clinical findings including inspiratuar stridor, suprastrenal retractions and cough. But chest X-ray and lateral view of the neck did not show subglottic stenosis. Also, clinical status worsens in spite of treatment including dexamethasone and cool air against croup syndrome. We cannot demonstrate foreign body in chest X-ray or computerized thorax tomography because plastic part of toy is radiolucent. Radiopaque foreign bodies can be detected in 4–30% of the patients with FBA [3]. Hence, children with suspicious and progressive history or symptoms should undergo prompt bronchoscopy.

FBA is a serious and life-threatening situation that requires special attention during childhood and should also be considered in children with respiratory distress unresponsiveness with the conventional treatment modalities. A careful and persisting history and clinical suspicion can provide with accurate diagnosis and bronchoscopy should be used as a diagnostic and treatment modalities. While the most common cause of nontraumatic pneumomediastinum, subcutaneous emphysema and epidural emphysema in children may be asthma or respiratory infection, FBA should be considered.

Back to Article Outline

References 

  1. Oguzkaya F, Akcali Y, Kahraman C, Bilgin M, Sahin A. Tracheobonchial foreign body aspirations in childhood: a 10-year experience. Eur. J. Cardiothorac. Surg. 1998;14:388–392
  2. Laks Y, Barzilay Z. Foreign body aspiration in childhood. Pediatr. Emerg. Care. 1988;4:102–106
  3. Midulla F, Guidi R, Barbato A, Capocaccia P, Forenza N, Marseglia G, et al. Foreign body aspiration in children. Pediatr. Int. 2005;47:663–668
  4. Findlay CA, Morrisey S, Paton JY. Subcutaneous emphysema secondary to foreign-body aspiration. Pediatr. Pulmonol. 2003;36:81–82
  5. Karakoc F, Karadag B, Akbenlioglu C. Foreign body aspiration: what is the outcome?. Pediatr. Pulmonol. 2002;34:30–36
  6. Tambe P, Kasat LS, Tambe AP. Epidural emphysema associated with subcutaneous emphysema following foreign body in the airway. Pediatr. Surg. Int. 2005;21:721–722
  7. Gesundheit B, Preminger A, Harito B, Babyn P, Maayan C, Mei-Zahav M. Pneumomediastinum and subcutaneous emphysema in an 18-month-old child. J. Pediatr. 2002;141:116–120
  8. Damore DT, Dayan PS. Medical causes of pneumomediastinum in children. Clin. Pediatr. (Phila.). 2001;40:87–91
  9. McSweeney WJ, Stempel DA. Non-iatrogenic pneumomediastinum in infancy and childhood. Pediatr. Radiol. 1973;1:139–144
  10. Caramella D, Bulleri A, Battolla L, Pifferi M, Baldini G, Bartolozzi C. Spontaneous epidural emphysema and pneumomediastinum during an asthmatic attack in a child. Pediatr. Radiol. 1997;27:929–931
  11. Satoh K, Kawase Y, Kobayashi T. Anorexia nervosa: an association with certain types of soft tissue emphysema. Nihon Kyobu Shikkan Gakkai Zasshi. 1994;32:685–688(Abstract)
  12. Tsuji H, Takazakura E, Terada Y. CT demonstration of spinal epidural emphysema complicating bronchial asthma and violent coughing. J. Comput. Assist. Tomogr. 1989;13:38–39
  13. Drevelengas A, Kalaitzoglou I, Petridis A. Pneumorachis associated with spontaneous pneumomediastinum. Eur. J. Radiol. 1994;18:122–123
  14. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. Pediatr. Surg. 1994;29:682–684

PII: S1871-4048(07)00076-7

doi:10.1016/j.pedex.2007.09.005

International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 1 , Pages 35-38, January 2008

Article Tools

* Image Usage & Resolution