Crunching Heartbeat

Pneumomediastinum is an uncommon entity in pediatric practice, with a peak of incidence during adolescence, particularly affecting tall, thin males. It is defined as free air within the mediastinum and its etiology is multifactorial, spontaneous or idiopathic. The most common symptom of spontaneous pneumomediastinum (SPM) is chest pain; however, most patients are asymptomatic. The pain is characteristically pleuritic, retrosternal and intensified by movement, breathing, and position changes. Other common symptoms are dyspnea, cough, neck pain, odynophagia and dysphagia.

We report a case of a previously healthy, 15-year-old male adolescent, high performance athlete, who was admitted to the hospital with three days evolution chest pain, which began a few hours after an intensive sports practice. The pain irradiated to the neck and was intensified by deep breathing. No shortness of breath, weakness, heart palpitations or other heart symptoms were associated. There was no history of respiratory infections, invasive procedures or trauma in the previous days.

On physical examination he had palpable subcutaneous neck emphysema and a crunching sound in cardiac auscultation, synchronous with the heartbeat. Chest and neck radiography confirmed ectopic air in the mediastinum and subcutaneous neck emphysema. The treatment consisted in rest and avoidance of maneuvers that could increase pulmonary pressure. Clinical symptoms resolved after 5 days and there were no radiologic findings at a 7 day follow up.

Hamman`s sign, Hammond`s sign or Hammond`s crunch is a rare but pathognomonic sign characterized by a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium. This sound is produced by the heart beating against air-filled tissues. SPM diagnosis can be made by physical examination and chest radiography or computed tomography may be helpful to document the diagnosis.

This case highlights the importance of physical examination in SPM diagnosis, especially in the presence of the pathognomonic Hamman’s sign.