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Hamman’s syndrome – with audio file recording Hamman’s sign
Abstract
A boy in his late adolescence, with no history of airway disease or medication use, presented with acute history of non-exertional chest pain increased on coughing and deep inspiration accompanied by dysphonia and odynophagia in the last 1 day. He had a notable history of viral fever with non-productive cough 2 weeks prior, which resolved spontaneously. Examination revealed stable haemodynamic parameters. Palpable non-tender crepitus was felt in left anterior chest wall, axilla and both sides of the neck. Auscultation revealed Hamman’s sign. ECG showed high voltage complexes and 2-dimensional echocardiogram (2D ECHO) showed normal biventricular function. CXR was evident of subcutaneous emphysema, pneumopericardium and Naclerio’s sign clinching the diagnosis of pneumomediastinum. CT findings were consistent with a diagnosis of Hamman’s syndrome. Patient was admitted for observation and treated with high-flow oxygen. He improved symptomatically and was discharged on the fourth day of admission.
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Hamman's syndrome is an uncommon complication of labor. Its diagnosis is based on clinical suspicion and CT imaging. It is often a benign and self-limiting condition occurring in healthy patients. The risk factors are nulliparity and a prolonged second stage of labor. Hamman's syndrome has life-threatening implications that underscore the importance of early diagnosis and management to avoid any difficulty.
This paper discusses the case of a 21-year-old, healthy female without allergies who was admitted to the hospital in spontaneous labor at 40 weeks of gestation. During the second stage of labor, she developed Hamman's syndrome and presented with subcutaneous emphysema, which led to an emergency C-section. After a chest and cervical CT scan that showed extensive subcutaneous emphysema and a pneumomediastinum, the patient was admitted to the ICU.
The authors present the case of a previously healthy, 22-year-old male nonsmoker who sought emergency room treatment complaining of retrosternal pain. He reported a history of odynophagia two days before, followed by produc- tive cough, fever and dyspnea. On chest radiography, a line could be observed surrounding the heart and the continuous diaphragm sign. The chest computed tomography scan confirmed the presence of pneumomediastinum and soft tissue emphysema. The case was discussed in a multidisciplinary team, and the possibility of surgical intervention was rejected. Conservative treatment was decided with complete resolution of the pneumomediastinum.
Spontaneous pneumomediastinum is defined as the presence of free air in the mediastium in the absence of any obvious precipitating cause. The purpose of this study was to review our experience with this condition, discuss mechanisms and provide a management algorithm.
A retrospective audit of patients admitted with spontaneous pneumomediastinum between 2003 and 2008 was performed. A total of 17 patients were identified.
Common predisposing factors for spontaneous pneumomediastinum were alcohol excess, asthma and illicit drug use. Vomiting and coughing were common precipitating factors. There was no morbidity, mortality or recurrence. Patients were admitted under a number of different specialties.
Spontaneous pneumomediastinum is a benign self-limiting condition that requires early differentiation from more serious causes, in particular Boerhaave's syndrome.
A case of spontaneous mediastinal emphysema (Hamman's syndrome) is described. The patient was a 21-year-old man, who had a sudden onset of substernal chest pain at rest associated with typical findings of Hamman's syndrome: subcutaneous emphysema of the neck, a precordial crunching sound synchronous with the heart beat and air in the mediastinum on chest x-ray. He recovered uneventfully. The pathogenesis and clinical picture of this rare condition are discussed.
To evaluate the clinical characteristics and natural history of patients presenting with spontaneous pneumomediastinum.
A retrospective case series was conducted to identify patients diagnosed with spontaneous pneumomediastinum. ICD-9 discharge codes were used for 1984 to 1990 at two institutions, and emergency department records of a third hospital were reviewed for 1981 to 1986. Clinical features, interventions, complications, setting, etiology, symptoms, and length of hospital stay were recorded.
Three university tertiary care hospitals.
All ED patients more than 12 years old with a diagnosis of spontaneous pneumomediastinum.
None.
Seventeen cases were identified. Age range was 15 to 41 years (mean, 25 years). Presenting symptoms were chest pain in eight (47%), dyspnea in three (18%), both symptoms in three (18%), and neither in three (18%). Three patients complained only of throat discomfort. Nine (52%) had a Hamman's crunch, 11 (65%) had subcutaneous emphysema, and two (11%) had a small pneumothorax. Five (29%) were smokers, and five (29%) had normal esophograms. Thirteen of 17 (76%) cases were associated with illicit inhalation drug use. Twelve cases (70%) had history of a "Valsalva-type" maneuver. All but three were admitted to a hospital, with a mean stay of 2.5 days (range, one to six). No patient suffered complications or required interventions for spontaneous pneumomediastinum. Specifically, no patient developed a subsequent pneumothorax or airway compromise. The three patients not admitted were followed up by telephone contact. All did well with rapid resolution of their symptoms.
Most spontaneous pneumomediastinum cases occur in the setting of inhalational drug use. One hundred percent of patients will have a symptom directly related to the spontaneous pneumomediastinum, with 82% presenting with either dyspnea or chest pain. Most (88%) will present with either subcutaneous emphysema or a Hamman's crunch on examination. Simple spontaneous pneumomediastinum has a very benign course and does not require hospitalization. Serial radiographs, likewise, did not change the medical management of spontaneous pneumomediastinum.
To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management.
A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated.
The emergency department referrals of two major Melbourne teaching hospitals.
SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.