Complication of tracheotomy: A case of fatal pneumomediastinum in spontaneous ventilation

Pneumomediastinum is defined as the presence of free air in the mediastinal space. It is classically defined as either spontaneous or secondary pneumomediastinum, depending on whether a cause can be recognised (e.g. trauma, intrathoracic infections or medical procedures such as dental or facial surgery and tracheotomy). It can be associated with pneumothorax and subcutaneous emphysema of the cervico-facial area because of the ascent of the air from the mediastinum towards the neck. To our knowledge, only one case of death from pneumomediastinum due to tracheotomy has previously been recorded. We report a case of death due to pneumomediastinum, which occurred in a patient with a tracheotomy during spontaneous ventilation. The 65-year-old man underwent surgical mandibular reconstruction with a custom-made titanium plate for osteonecrosis with temporary tracheotomy. The patient received mechanical ventilation only during surgery. On day 3, when the tracheotomy was closed, the patient experienced a rapid deterioration of lung ventilation with initial development of subcutaneous cervical emphysema. Although a tracheotomy tube was promptly inserted, the patient developed massive subcutaneous cervico-facial emphysema with a drop in oxygen capillary saturation. The man died after half an hour of resuscitation due to a massive pneumomediastinum. In this paper, we discuss the epidemiology, aetiology, physiopathology, complications and necropsy findings in pneumomediastinum, focusing on the aspects of our case compared to the only other case reported.