An approach from the neck to drain expanding pneumomediastinum: a case report

Background: Several methods for draining pneumomediastinum have been advocated, but no consensus has been established. We propose a novel method for draining air from pneumomediastinum. Case Description: We used an approach from the neck to drain pneumomediastinum that had started to compress the heart in a 33-year-old man with coronavirus disease 2019 (COVID-19) on mechanical ventilation. Computed tomography showed extension of pneumomediastinum to the lateral and dorsal aspects of the right sternocleidomastoid muscle, presenting as subcutaneous emphysema at the neck. We made a 4-cm incision lateral to the right sternocleidomastoid muscle. After incising the platysma muscle, the dorsal side of the sternocleidomastoid muscle was easily stripped off due to the presence of air, allowing placement of a 14-Fr Nelaton catheter. Subcutaneous emphysema as well as pneumopericardium on X-rays improved and disappeared by 3 days after starting drainage. Positive end-expiratory pressure (PEEP) was titrated in a stepwise manner from 6 to 10 cmH₂O, with no re-appearance of subcutaneous emphysema. The Nelaton catheter at the neck was removed and the skin was sutured using 3-0 Nylon monofilament. Conclusions: We propose this approach from the neck to release air and prevent deterioration of pneumomediastinum communicating with subcutaneous emphysema at the neck.