Routine fluoroscopic esophagography does not change clinical management of patients initially diagnosed with spontaneous pneumomediastinum: a dual-center retrospective study.

Background: The routine use of fluoroscopic esophagography (FE) to exclude esophageal perforation in patients with spontaneous pneumomediastinum (SPM) is widespread but lacks robust evidence. This study aimed to evaluate the clinical utility of this practice by assessing its impact on treatment decisions. Methods: We conducted a dual-center, retrospective cohort study of patients initially diagnosed with SPM. Sixty-three patients were categorized into an FE group (n=32) or a non-FE (observation) group (n=31) based on clinical practice at each center. The primary endpoint was the proportion of patients whose management changed due to the FE result. Secondary endpoints included clinical recovery rates and the prevalence of the Macklin effect on chest computed tomography (CT). Results: No esophagogram [0/32, 0.0%; 95% confidence interval (CI): 0.00-10.89%] revealed esophageal perforation or other findings that altered the clinical management plan. All patients in both groups achieved complete clinical recovery. Among patients with available CT imaging (n=50), 100% exhibited either definitive or suspected Macklin effect (95% CI: 92.89-100%). Conclusions: In patients clinically diagnosed with SPM, routine fluoroscopic FE has an extremely low probability of changing management. Its necessity appears limited when diagnosis is supported by clinical history and CT findings, particularly the presence of a Macklin effect. A selective, non-routine approach to esophagography in this setting is preliminarily supported as safe.