Surgical Drainage of Tension Pneumomediastinum in a Newborn: A Rare Lifesaving Intervention

A full-term male newborn was delivered via repeat cesarean section at a gestational age of 38 weeks and 1 day, with a birth weight of 3052 g and Apgar scores of 9/9 (1 and 5 min). Soon after birth, he developed grunting, tachypnea, and subcostal retractions. Despite receiving supplemental oxygen, he demonstrated worsening respiratory distress and was transferred to our neonatal intensive care unit (NICU) 9 h after birth. On admission, peripheral oxygen saturation (SpO₂) was 70%–80% while receiving support via nasal dual positive airway pressure (DPAP, 8 L/min, FiO₂ 0.5). His condition further deteriorated (SpO₂ 50%–60% and bradycardia). Chest radiography revealed a right-sided tension pneumothorax with a mediastinal shift (Figure 1A). Emergency insertion of an 8 Fr chest tube into the right pleural cavity through the fifth intercostal space improved oxygenation to approximately 90%. Tracheal intubation and mechanical ventilation followed. On day 1, chest computed tomography (CT) revealed an extensive pneumomediastinum compressing the mediastinal structures (Figure B1, B2) without congenital lung anomalies. With the clinical and radiological progression of the pneumomediastinum and persistent hypoxia accompanied by bradycardia, we suspected tension physiology with impaired mediastinal venous return. Given this progression, we performed mediastinal drainage via a right thoracotomy by inserting a 10 Fr trocar catheter into the mediastinum and an additional chest tube (Figure 1C). Postoperatively, the air leak from the pleural drain ceased, and oxygenation stabilized. The infant was extubated on day 5. Mediastinal and pleural drains were removed on days 7 and 8, respectively. The infant has remained free of recurrent pneumothorax or pneumomediastinum over 3 years of follow-up. Although most neonatal pneumomediastinum resolves with conservative management, rare tension forms causing mediastinal compression and circulatory compromise have been described in ventilated neonates requiring emergency surgical drainage [1, 2]. In older children, CT-guided mediastinal drainage has been shown to be a safe, minimally invasive, and effective option [3]. This case highlights two key clinical points. First, in neonates with pneumothorax, persistent or worsening respiratory distress despite adequate pleural drainage, and radiographic findings of air tracking in the mediastinum, tension pneumomediastinum rather than isolated pneumothorax should be suspected. On retrospective review, the initial chest radiograph in this case also demonstrated a subtle “angel wing sign,” an indicator of early pneumomediastinum. Although well-recognized among pediatric radiologists, this sign is likely underrecognized in general pediatric and neonatal intensive care practice. Greater awareness of this radiographic sign may support earlier diagnosis and appropriate care escalation. Second, surgical mediastinal drainage, although rarely indicated in neonates, can be lifesaving if radiographic or clinical deterioration occurs. Although neonatal chest tube placement is within the skill set of a neonatologist, mediastinal drainage is anatomically complex and requires pediatric surgical expertise. In this case, early collaboration with pediatric surgeons enabled timely intervention and a favorable outcome. This report is inherently limited as a single, retrospective case without hemodynamic monitoring or intrathoracic pressure measurements. Prospective collection of similar cases with standardized physiologic data and imaging could help refine thresholds and criteria for when surgical mediastinal decompression should be undertaken. In summary, this case demonstrates that when neonatal tension pneumomediastinum occurs, hesitation may be fatal, and prompt surgical drainage can be lifesaving. We believe that this report provides valuable evidence supporting heightened vigilance and readiness to surgically intervene in similar clinical scenarios. Taku Yamamichi: conceptualization, data curation, methodology, formal analysis, visualization, writing – original draft, project administration, investigation. Souji Ibuka: supervision, writing – review and editing, resources. Sadanori Yamashita: supervision and resources. Kenji Takahashi: resources and supervision. Shun Iwasaki: supervision, writing – review and editing, resources. Ryuta Saka: supervision, resources, validation, writing – review and editing, project administration. Informed consent for publication was obtained from the parents of the study participant. An institutional review was not required for an anonymized single-case report. The authors declare no conflicts of interest. No datasets were generated or analyzed for this clinical correspondence. All information is contained within the article.