CT scans can effectively rule out esophageal perforation in patients with spontaneous pneumomediastinum.

• Of 82 patients, only 14 (17.1%) had a confirmed perforation, all showing pleural or mediastinal fluid.
• Pleural/mediastinal fluid had 100% sensitivity and negative predictive value for perforation.

Patients without pleural or mediastinal fluid can avoid unnecessary transfers and further testing.

• Perforation patients were older (median age 48 vs. 31) and more likely to report dysphagia (29% vs. 7.4%).