Diagnostic Utility of Computed Tomography in Patients With Spontaneous Pneumomediastinum Evaluated for Suspected Esophageal Perforation.

Abstract

Spontaneous pneumomediastinum (PM) is an uncommon radiographic finding that may indicate esophageal perforation and lead to further evaluation including transfer to a tertiary care center. We evaluated computed tomography (CT) findings and associated clinical features in patients with a suspected spontaneous esophageal perforation. We retrospectively reviewed records of adults referred to a tertiary care center (January 2020-December 2024) for suspected spontaneous esophageal perforation with PM on CT. Patients with a history of recent surgery, endoscopy, or trauma were excluded. Clinical and imaging features between patients with and those without a confirmed perforation were compared by univariate analysis. Eighty-two patients were included; 14 (17.1%) had a confirmed esophageal perforation and 68 (82.9%) did not. All perforations were noted in patients with pleural and/or mediastinal fluid (P/M fluid) and none were noted in patients without either. P/M fluid demonstrated a sensitivity of 100% and NPV of 100% for perforation (p < 0.001). Patients with a perforation were significantly older (median 48 vs. 31 years; p = 0.013), more commonly reported dysphagia (29% vs. 7.4%; p = 0.042), had a higher white blood cell count (median 18.8 vs. 11.5 × 10³/μL; p = 0.004), more often presented with respiratory compromise (43% vs. 5.9%; p = 0.001), and had longer hospital stays (median 13.0 vs. 2.0 days; p < 0.001) than those without; other symptoms (e.g., abdominal pain, vomiting, chest pain, and shortness of breath) and vital signs (laboratory values, including hemoglobin, CO₂, and creatinine) were similar between groups (p > 0.05). Patients with spontaneous PM on CT without pleural and/or mediastinal fluid are not at risk of esophageal perforation and can avoid further testing and transfer.