Base of skull fracture leading to pneumomediastinum and pneumo-retroperitoneum: a case report with review of literature (original) (raw)
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Pneumothorax and concomittant idiopathic pneumoperitoneum - at blunt thoracic trauma. Case Reporting
2019
Shqiptar Demaçi*, Bedri Osmani, Fitim Selimi, Saudin Maliqi, Yllka Krasniqi ( Thoracic Surgery Clinic , University Clinical Center of Kosova-Prishtina; UBT – University for Business and Technology- Kosova ) Pneumothorax and idiopathic concomittant pneumoperitoneum - at blunt thoracic trauma. Case report Abstract: The presence of concomitant pneumoperitoneum in a severed corporal injury (head, neck / thorax / abdomen) with more pronounced thoracic injury is extremely rare and the exact mechanism of its presentation is unknown (idiopathic). The dilemma lies in deciding whether or not to have surgical treatment. The case of a 31-year-old injured person who accidentally falls off the stairs and falls downstairs (2.5 - 3 meter height) on a grate-reinforced base and being treated after all clinical and imaging tests, and careful observation a week is only done in a conservative (non-surgical) way, bed regimen and empirical therapy: antibiotics and analgesics. Literature is consulted and suggestions are given. Keywords: blunt chest trauma, pneumothorax; idiopathic pneumoperitoneum; *Corresponding author: Shqiptar Demaçi, email: shdemaci@hotmail.com; University Clinical Center of Kosova-Prishtina; UBT – University for Business and Technology- Kosova Introduction: Pneumoperitoneum (PP) is a radiological finding that is indicative of severe abdominal disease. 90% of PP cases result from perforated organs demonstrated as free intraperitoneal air on radiography. [1] Pneumoperitoneum is caused as air enters through the abdominal wall, diaphragmatic wall or retroperitoneum. [2] Pneumoperitoneum caused by blunt trauma usually indicates the need for emergency laparotomy. However in 5 ~ 15% of cases with pneumoperitoneum no surgical management is required, because the air comes from sources other than the cavity organs. [3] The other type of idiopathic PP, which is much rarer, is that associated with pneumothorax secondary to trauma. [4-9] In these cases, air from the thorax enters through the rupture of the lungs and finds the dissection inserted into the retroperitoneum or inserted directly through the diaphragm defect [10] Diagnosing PP in this group of patients does not necessarily mean that there is true gastrointestinal perforation therefore surgery is not always required. Conservative treatment and careful observation can avoid unnecessary surgery in these patients. [11] Case report The injured, male 31 years old, is admitted to the Thoracic Surgery Clinic - UCCK Prishtina, to be treated for injuries received as a result of slipping while walking up the stairs and falling from the first floor to a reinforced concrete base (reinforcement) ). There is pain in the head, right side-chest, accompanied by difficulty breathing and abdominal pain. Laboratories: hematocrit 0.47; easily elevated aspartate amino transferase (AST): 96 U / L (reference values for males 10-40 U / L); Imaging: CT of the natural chest / abdomen (no contrast) on the day of injury shows minimal right anterior-apical pneumothorax (fig.1), basal pulmonary contusions-right side; pleural effusion-right side. The pneumomediastinum-right side is also seen (fig 2). Thoracic drainage is done on the right side, from where air and blood -100 ml are drained . The abdominal organs are without traumatic changes; subcutaneous emphysema along the left abdominal oblique muscle; Two days later CT of the abdomen / pelvis shows significant amounts of free intraabdominal air (intra and retroperitoneal) (Fig.3) - pneumoperitoneum and in some CT scans of the thorax hemopneumothorax is seen on the right side with the presence of drainage on the right side. Two days after trauma, the abdominal surgeon finds slight tenderness in the epigastric region. On native chest / abdomen radiographs (fig.4) there is transparency (air) under the diaphragmatic domes. Six days after injury the air persists under the diaphragmatic domes but this does not correspond to the stable clinical condition of the patient. There is no abdominal pain. One week after the injury, the esophagus and gastroduodenum are passed with hydrosoluble contrast per os and it is found: normal esophageal passage; no radiological signs are observed for hiatal hernia nor for diaphragmatic rupture . Fig.1. CT thorax/ Pneumothorax –r ight side Fig. 2. Pneumomediastinum (billateraly) Fig.3.Pneumoperitoneum on CT scann ( sagittal plan) Fig.4.Pneumoperitoneum on native X-ray of chest(thoracic drain in situ)and abdomen Discussion To date, no definitive explanation has been given for the presence of Pneumothorax or pneumomedistinum associated with pneumoperitoneum (PP). The association between pneumothorax and idiopathic PP has been reported in several case-study studies in patients who have suffered blunt trauma. [4-9] Based on some reliable experimental studies, it has been said that interstitial emphysema develops when the intratracheal pressure exceeds 40 cm of the water column, pneumomediastinum develops in 50 cm of the water column, pneumoperitoneum may appear when the pressure exceeds 60 cm of the water column. [12] As a hypothetical model, the increased intrathoracic air pressure dissects the planes / fascial layers close to the mediastinum. Air can then dissect through various spaces including the pleura and along the esophagus and large thoracic vessels to the retroperitoneum, from where it can then rupture into the peritoneal cavity. [13] Hefny et al. (14) (2014) showed that free intraperitoneal air found on CT in patients with blunt abdominal trauma (21 cases) is an unsafe radiological finding for intestinal perforation and the decision for laparotomy should be based on combined clinical and radiological findings. They suggest for active observation with conservative management that may avoid unnecessary laparotomy. Since the study is retrospective with a small number of cases - the conclusion can not be reached. In the clinical case evaluated by us, there is association of PP with pneumothorax with small amount of blood in the right chest and small amount of pneumomediastinum. Since there is no general clinical surgical detachment nor from the abdominal or thoracic side, its treatment is done conservatively. Conclusion: In cases with associated PP, in blunt injuries of the body or chest / abdomen, the clinical condition should be carefully evaluated in accordance with the CT imaging findings and, depending on them, conservative or surgical treatment should be performed. Literature: 1. McGlone FB, Vivion CG Jr. Spontaneous pneumoperitoneum. Gastroenterology. 1966;51:393-398) 2. Di Saverio S, Filicori F, Kawamukai K,Boaron M,Tugnoli G. Combined pneumothorax and pneumoperitoneum following blunt trauma: an insidious diagnostic and therapeutic dilemma. Postgrad Med J 2011;87:75–8, http://dx.doi.org/10.1136/pgmj.2010.110262) 3. Mularski RA, Sippel JM, Osborne ML. Pneumoperitoneum: a review of nonsurgical causes. Crit Care Med 2000;28:2638-44. 4. Glauser FL, Bartlett RH. Pneumoperitoneum in association with pneumothorax. Chest. 1974;66:536-540]; 5. Andrew TA, Milne DD. Pneumoperitoneum associated with pneumothorax or pneumopericardium: a surgical dilemma in the injured patient. Injury. 1979;11:65-70]; 6. Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma. 2003;54:1254. 7. Gardner-Thorpe D, Maddox PR. Idiopathic pneumoperitoneum following blunt chest trauma: a case report. Injury. 1999;30:511-513. 8. Hamilton P, Rizoli S, McLellan B, et al. Significance of intraabdominal extraluminal air detected by CT scan in blunt abdominal trauma. J Trauma. 1995;39:331-333. 9. Krausz M, Manny J. Pneumoperitoneum associated with pneumothorax: a surgical dilemma in the posttraumatic patient. J Trauma. 1977;17:238-240. 10. Ferrera PC, Chan L. Tension pneumoperitoneum caused by blunt trauma. Am J Emerg Med. 1999;17:351-353. 11. Ilya Sabsovich; Ravi Desai, Rafael Alba, Jose Yunen, David Sammett. Idiopathic pneumoperitoneum after blunt chest trauma; May 09, 2008. MD Magazine Resources 12. Grosfeld J.L., Boger D., Clatworthy H.W., Jr. Hemodynamic and manometric observations in experimental air-block syndrome. J Pediatr Surg. 1971;6:339–344; 13. Assenza M., Passafiume F., Valesini L., Centonze L., Romeo V., Modin C. Pneumomediastinum and pneumoperitoneum after blunt chest trauma: the Macklin effect. J Trauma Treat. 2012;1(1):1–5. 14. Hefny A.F., Kunhivalappil F.T., Matev N., Avila N.A., Bashir M.O., Abu-Zidan F.M. Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital. Injury. 2014;(September 16) pii:S0020-1383(14)00431-8
Non-perforated Traumatic Pneumoperitoneum in Maxillofacial Trauma: A Compelling Case Report
Cureus, 2024
Pneumoperitoneum typically results from intraabdominal gas due to gastrointestinal perforation, with exploratory laparotomy serving as the standard management. While non-surgical causes are well established, instances where pneumoperitoneum lacks an identifiable cause even after laparotomy are sparsely documented. Here, we present a case involving a 22-year-old male who, following a high-velocity road traffic injury resulting in a panfacial fracture, exhibited gross subcutaneous emphysema in the neck, pneumomediastinum, and pneumoperitoneum. This report aims to contribute to the growing understanding of such cases, potentially leading to the development of a management protocol that may help avoid unnecessary laparotomies in similar scenarios.
Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma
International Journal of Surgery Case Reports, 2014
INTRODUCTION: Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen. PRESENTATION OF CASE: We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed. CONCLUSION: Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.
Pneumomediastinum in blunt chest trauma: a case report and review of the literature
Case reports in emergency medicine, 2014
Blunt trauma is the most common mechanism of injury in patients with pneumomediastinum and may occur in up to 10% of patients with severe blunt thoracic and cervical trauma. In this case report we present a 24-year-old man with pneumomediastinum due to blunt chest trauma after jumping from a bridge into a river. He complained of persistent retrosternal pain with exacerbation during deep inspiration. Physical examination showed only a slight tenderness of the sternum and the extended Focused Assessment with Sonography for Trauma (e-FAST) was normal. Pneumomediastinum was suspected by chest X-ray and confirmed by computed tomography, which showed a lung contusion as probable cause of the pneumomediastinum due to the "Mackling effect." Sonographic findings consistent with pneumomediastinum, like the "air gap" sign, are helpful for quick bedside diagnosis, but the diagnostic criteria are not yet as well established as for pneumothorax. This present case shows that de...
Laryngeal Fracture due to Blunt Trauma Presenting with Pneumothorax and Pneumomediastinum
ORL, 2011
Aim: Injuries due to traffic accidents are frequent in childhood, and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal fracture in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum and pneumothorax. Case: A 14-year-old girl was referred for pneumomediastinum. Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. Chest tomography revealed pneumothorax and pneumomediastinum, and cranial tomography revealed maxillofacial fractures. Upper airway damage was suspected, flexible endoscopy revealed right vocal cord paralysis and cervical tomography revealed thyroid cartilage fracture. The fracture was repaired and tracheotomy was performed. She was discharged on postoperative day 6. Facial fractures were repaire...
Closed Thoracic Trauma as an Exceptional Cause of Pneumorrhachis: A Case Report
Curēus, 2024
Pneumorrhachis, a rare clinical entity, refers to the presence of air in the spinal canal. Air can enter the spinal canal through various pathways, including the lungs and mediastinum (the space between the lungs), or directly from external sources due to trauma or infection. In rare cases, pneumorrhachis may result from repeated secondary Valsalva maneuvers, which is a complication of large-area pneumothorax. In this case report, we discuss a 36-year-old male patient who was involved in a high-intensity road accident. The injury assessment revealed significant findings including a large left pneumothorax, a right pneumothorax, multiple rib fractures, and the presence of pneumorrhachis. The entry of air into the spinal canal originated from the pleural space, likely through injuries to the parietal pleura. Rarely reported, closed thoracic trauma is an exceptional cause of pneumorrhachis. This unique mechanism of injury has been described in a limited number of publications addressing traumatic pneumorrhachis. The identification of pneumorrhachis in a traumatized patient should prompt further investigation to explore other potential injuries that may elucidate the formation of this intraspinal gas collection.
2013
Introduction: Pneumoperitoneum is a striking feature of hollow viscous perforation and may need of immediate surgical intervention. Blunt trauma chest with pneumoperitoneum without evidence of hollow viscous perforation is unusual and the condition called spontaneous pneumoperitoneum. Case Presentation: A 29 year male presented to the emergency department after a road traffic accident with hypotension and respiratory distress. Clinically there was surgical emphysema associated with diminished breath sound over left half of the chest and multiple contusions over left hypochondrium and left flank. Bedside X-ray showed fracture of ribs on left side with pneumothorax and air under both the dome of diaphragm. Emergency tube thoracostomy done and respiratory symptoms improved. Further patient evaluated with Ultrasound abdomen and Computerized tomogram of abdomen. Imaging study revealed dilated bowel loops, gross pneumoperitoneum with minimal fluid collections. We did diagnostic laparoscopy done to find hollow viscous perforation or diaphragm injury but to the surprising hollow viscous and diaphragm found to be normal. Case Discussion: Pneumothorax and pnemoperitoneum with presence of abdominal contusions make the surgeons in dilemma for choosing conservative or therapeutic approach. Conclusion: Diagnostic laparoscopy with systemic exploration of abdominal organs and spaces will help in diagnosis and mandatory laparotomy may avoided
Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment
The Spine Journal, 2011
BACKGROUND CONTEXT: Traumatic pneumorrhachis (PR) is a rare entity, consisting of air within the spinal canal. It can be classified as epidural or subarachnoid, identifying the anatomical space where the air is located, and is associated with different etiologies, pathology, and treatments. PURPOSE: To conduct a systematic review of the scientific literature focused on the etiology, pathomechanism, diagnosis, and treatment of PR, and to report a case of an asymptomatic epidural type. STUDY DESIGN: International medical literature has been reviewed systematically for the term ''traumatic pneumorrhachis'' and appropriate related subject headings, such as traumatic intraspinal air, traumatic intraspinal pneumocele, traumatic spinal pneumatosis, traumatic spinal emphysema, traumatic aerorachia, traumatic pneumosaccus, and traumatic air myelogram. All cases that were identified were evaluated concerning their etiology, pathomechanism, and possible complications. SAMPLES: Studies that included one of the aforementioned terms in their titles. METHODS: A systematic review was performed to identify, evaluate, and summarize the literature related to the term ''traumatic pneumorrhachis'' and related headings. Furthermore, we report a rare case of an asymptomatic epidural PR extending to the cervical and thoracic spinal canal. We present the current data regarding the etiology, pathomechanism, diagnosis, and treatment modalities of patients with PR. RESULTS: The literature review included 37 related articles that reported 44 cases of traumatic PR. Only isolated case reports and series of no more than three cases were found. In 21 cases, the air was located in the epidural space, and in 23 cases, it was in the subarachnoid space. Most of the cases were localized to a specific spinal region. However, eight cases extending to more than one spinal region have been reported. CONCLUSIONS: Traumatic PR is an asymptomatic rare clinical entity and often is underdiagnosed. It usually resolves by itself without specific treatment. We stress the significance of this information to trauma specialists, so that they may better differentiate between epidural and subarachnoid PR. This is of great significance because subarachnoid PR is a marker of severe injury. The management of traumatic PR has to be individualized and frequently requires multidisciplinary treatment, involving head, chest, and/or abdomen intervention. Ó