Background:
This study investigated the incidence of oesophageal perforations (OP) in cases of pneumomediastinum (PNM) diagnosed on high-resolution computed tomography (CT) from the Emergency Department (ED). The aim was to identify clinical, biochemical, and radiological features of OP and determine if a set of criteria can reliably predict OP without the need for further investigations (i.e., endoscopy).
Methodology:
A retrospective analysis of 427 adult patients was conducted with index CT scan reports containing 'pneumomediastinum' from January 2016 to December 2022 at a tertiary institution. Patients with pre-existing PNM or recent interventions were excluded from the study. Patient demographics, symptoms, biochemical markers, and radiological findings were analysed to identify predictors of OP.
Results:
336 patients with PNM were included, of which 22 patients were diagnosed with OP. Clinical features of dysphagia (p=0.003) and vomiting (p=0.007) had significant correlation with an OP. Patients with no reported symptoms reliably excluded OP (p=0.002). Radiological findings of pleural effusion, mediastinal free fluid, and disruption of oesophageal wall were all highly sensitive features for OP (p<0.001).
Conclusion:
This study provides evidence to aid clinical decision-making in PNM cases by identifying risk factors for patients who are at risk of OP. Asymptomatic patients are unlikely to have OP and can generally often be discharged with safety-netting. The presence of dysphagia, pleural effusion, mediastinal free fluid, or visible disruption of the oesophageal wall on CT were high risk features. This data will help clinicians in risk stratifying PNM patients and targeting the need for further investigations and treatment.