Diagnosis: Spontaneous Pneumomediastinum

Review of the patient's CXR was remarkable for evidence of pneumomediastinum and extensive subcutaneous emphysema around the neck. 

A CT chest was subsequently obtained and showed bilateral peribronchial thickening suggestive of bronchiolitis, as well as extensive pneumomediastinum. No evidence of pneumothorax. 

A CT neck was also obtained and showed extensive pneumomediastinum extending into the retropharyngeal space, transverse foramina, and central canal. Extensive subcutaneous emphysema was seen in the in deep soft tissues of the neck, supraclavicular regions, axillae, and left anterior chest wall. 

The patient was diagnosed with viral bronchiolitis producing cough that resulted in spontaneous pneumomediastinum. He was admitted to the cardiothoracic surgery service for observation. A repeat CXR the following morning showed no progression. The patient's chest pain and shortness breath improved over 24 hours. He was discharged the following day with follow-up with his primary care doctor.

Pneumomediastinum

 ***Gas in the mediastinal tissues***

Spontaneous 

• asthma, exertion, Valsalva, seizure, childbirth, intubation, endoscopy, inhaled drugs
• benign clinical course, resolves spontaneously

Secondary

• esophageal perforation, Boerhaave syndrome
• trauma
• pulmonary barotrauma 

Presentation 

• chest pain, dyspnea, throat/neck pain, dysphonia, dysphagia, subcutaneous emphysema in neck and face often with crepitus
• "Hamman's sign or crunch" = crunch sound auscultated with each heartbeat

Complications

• infection, pneumothorax, tension pneumothorax
• mediastinal air in the absence of cardiopulmonary compromise is not life threatening but a cause should be sought

Diagnosis

• Chest x-ray 
• mediastinal air, lucency around cardiac border and aorta
• subcutaneous emphysema
• pneumothorax or other clues as to the cause
• Other tests: Gastrografin or barium swallow, CT, endoscopy

Treatment

• supportive
• search for and manage coexisting conditions 
• airway management if any evidence of respiratory distress or airway compromise 

References: 

Levy SJ, Lex JR, Emergency Medicine: A Focused Review of the Core Curriculum, 1st Ed, 2008, Chapter 4: Thoracic and Respiratory Disorders, pages 236-237

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Pain in the Neck

A 22 year old otherwise healthy male presents to the emergency department with chief complaint of neck pain. He reports having a runny nose, sore throat, and productive cough for the past week that has since improved. Two hours prior to arrival he says the skin over his neck began to feel painful to touch, worsened by coughing and swallowing. Also endorses associated feeling of "warmth." 

On review of systems he endorses mild shortness of breath and chest pressure. He denies nausea, vomiting, diarrhea, headache, or rash.

A chest x-ray with PA and lateral views was obtained and is shown below: 

What is the diagnosis?

How would you manage this patient? 

Please leave a comment below and share your thoughts. 

The diagnosis for this case will be posted in approximately 1 week.