AJR 2001; 177:1416
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Pneumomediastinum Without Pneumothorax Caused by Esophageal Rupture
F. M. Lomoschitz1,2,
K. F. Linnau1 and
F. A. Mann1
1
Department of Radiology, University of Washington School of Medicine,
Harborview Medical Center, Box 359728, 325 Ninth Ave., Seattle, WA
98104-2499.
2
Present address: Department of Radiology, University of Vienna, Waehringer
Guertel 18-20, A-1090 Vienna, Austria.
Received April 30, 2001;
accepted after revision May 8, 2001.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee
B. Talner.
Address correspondence to F. A. Mann.
Introduction
A 58-year-old female restrained driver complained of severe chest pain and
left upper quadrant abdominal pain after a high-speed motor vehicle crash. She
had undergone left pneumonectomy for lung cancer 5 years earlier. Chest
radiography showed left paramedian mediastinal and left pneumonectomy cavity
linear gas (Fig. 1A). CT showed
gas collections surrounding the distal esophagus and extending into the left
pneumonectomy cavity (Fig. 1B).
An emergent single-contrast esophagram showed contrast extravasation above the
gastroesophageal junction (Fig.
1C). At thoracotomy, a left-sided 4-cm longitudinal rent of the
distal esophagus was débrided and
repaired.
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Fig. 1A. —Distal esophageal rupture after blunt injury in 58-year-old
woman with history of left pneumonectomy. Anteroposterior chest radiograph
shows pneumomediastinum (arrowheads) and supradiaphragmal gas
extension into left-sided pneumonectomy cavity (arrows).
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Fig. 1B. —Distal esophageal rupture after blunt injury in 58-year-old
woman with history of left pneumonectomy. Enhanced helical CT scan shows
paraesophageal pneumomediastinum (white arrow) and thickened
esophageal wall (black arrow). Also note splenic injury with adjacent
hematoma.
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Fig. 1C. —Distal esophageal rupture after blunt injury in 58-year-old
woman with history of left pneumonectomy. Single-contrast esophagram obtained
by injection of 40 cc of water-soluble nonionic contrast material through
nasogastric tube shows contrast extravasation (arrows) at left-sided
rupture of distal esophagus.
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Most recognized radiographic findings for pneumomediastinum, whether seen
on conventional radiographs or CT scans, do not correlate with a particular
pathology. However, three obvious injuries of the aerodigestive tract have
suggestive radiographic signs. First, perforation of the larynx, proximal
trachea, or cervical esophagus may show deep cervical or parapharyngeal
emphysema. Second, rupture of the trachea or the main bronchi may show
intramural gas in the proximal airways (double wall sign). Lastly, rupture of
the distal esophagus may show extraluminal gas outlining the descending aorta
and dissecting the parietal pleura from the medial left hemidiaphragm
(Naclerio's V sign) [1], a
variant of which is seen in this patient.
Among patients with blunt trauma, deep cervical and mediastinal emphysema
without accompanying pneumothorax suggests injury to the aerodigestive tract.
Emergent evaluation with esophagography and laryngobronchoscopy is indicated
because untreated esophageal and major airways injuries may be life
threatening [2].
Although an uncommon sequela of blunt trauma, perforation of the esophagus
most commonly occurs in the cervical portion as a result of direct force to
the neck or laceration by fracture fragments (e.g., vertebral body).
Perforation of the distal esophagus after blunt trauma is rare. The cause of
these injuries is uncertain, but the mechanism may be similar to that
occurring in Boerhaave's rupture if sudden high esophageal intraluminal
pressure is generated at the time of injury
[3,
4].
On CT, extraluminal air is the most useful finding, reported in up to 92%
of patients with rupture of the distal esophagus. Focal thickening of the
esophageal wall and paraesophageal fluid collection, consistent with edema and
hemorrhage, often represent the level of perforation
[5].
When findings on conventional radiography or CT suggest a perforation, the
diagnosis is readily confirmed by esophagography with water-soluble contrast
medium. We perform supine cineesophagography (3 frames/sec) by hand injection
of nonionic water-soluble contrast material through a feeding tube initially
positioned in the distal esophagus in a left posterior oblique projection.
Second and third injections are made after repositioning of the feeding tube
into the proximal esophagus and hypopharynx, respectively. When no evidence of
perforation is found, esophagography is either repeated with barium-containing
contrast media in a right posterior oblique projection or CT of the
mediastinum is performed immediately after esophagography with water-soluble
contrast material. Either procedure increases the specificity for the
diagnosis of esophageal perforation
[6,
7].
References
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esophagography and CT. AJR
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