Pneumomediastinum requiring thoracic surgery consultation: etiology, management, and clinical outcomes

Pneumomediastinum is an uncommon clinical finding characterized by the presence of free air within the mediastinum and may arise from a variety of underlying conditions. In clinical practice, thoracic surgeons are frequently consulted to evaluate pneumomediastinum, primarily to exclude life-threatening causes such as airway or esophageal injury. However, data describing pneumomediastinum specifically from a thoracic surgery consultation perspective remain limited. This retrospective observational study included all consecutive patients consulted to the thoracic surgery service for pneumomediastinum at a tertiary care center between January 2023 and December 2025. Demographic data, etiological classification, management strategies, and clinical outcomes were analyzed. Patients were categorized into six etiological groups: spontaneous pneumomediastinum, barotrauma/mechanical ventilation-related, trauma-related, iatrogenic airway-related, gastrointestinal-related perforation, and mediastinitis-related pneumomediastinum. Sixty patients were included in the study. The median age was 49 years (IQR 29–65), and 75% were male. ICU admission occurred in 38 patients (63.3%), and 32 patients (53.3%) required mechanical ventilation. Barotrauma/mechanical ventilation-related pneumomediastinum ( n = 15), trauma-related pneumomediastinum ( n = 14), and spontaneous pneumomediastinum ( n = 12) were the most common etiologies. Concomitant pneumothorax and chest tube thoracostomy were most frequent in trauma-related cases (57.1% and 50.0%, respectively). Across all groups, pneumomediastinum itself rarely required direct intervention, and management was mainly directed toward the underlying pathology. In-hospital mortality ranged from 16.7% in spontaneous cases to 53.3% in barotrauma/mechanical ventilation-related cases, reflecting the markedly different clinical contexts represented in this selected cohort. Pneumomediastinum should be regarded as a heterogeneous clinical finding rather than a single disease entity. As this cohort was limited to patients referred for thoracic surgery consultation, these findings should be interpreted within this selected population rather than as representative of the overall epidemiology of pneumomediastinum. In thoracic surgical practice, management is largely determined by the underlying etiology. While spontaneous cases typically follow a benign course and can be managed conservatively, secondary pneumomediastinum often reflects more complex pathology requiring cause-specific evaluation and treatment. This study was conducted in accordance with the Declaration of Helsinki and approved by the Local Ethics Committee (Approval No: 20.478.486/3910, 26/02/2026). Given the retrospective nature of the study, the requirement for informed consent was waived by the ethics committee.