A 44 year old female presents for anterior neck pain and chest pain. She first noticed neck pain yesterday. This morning the pain has radiated into her chest. Symptoms are worse with swallowing. Patient denies fever, sore throat, cough, shortness of breath, vomiting, or voice change, or difficulty eating/drinking. Chest x-ray is shown below. What’s the diagnosis?
Answer: pneumomediastinum (see separation of pericardium from heart border)
- May also present with physical exam finding of “Hamman’s crunch” on heart auscultation
- Important to distinguish between primary (spontaneous/idiopathic) and secondary (traumatic, intrinsic lung disease, iatrogenic, and esophageal rupture)
- Rule out secondary with advanced imaging modalities such as non-contrast CT chest and upper GI gastrograffin swallow study
- Treatment is supportive care
- Spontaneous pneumomediastinum may be discharged from ED with close outpatient follow up for repeat imaging
References:
Wang Y.L., & Jones D (2020). Pulmonary trauma. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.
Bakhos, C. T., Pupovac, S. S., Ata, A., Fantauzzi, J. P., & Fabian, T. (2014). Spontaneous pneumomediastinum: an extensive workup is not required. Journal of the American College of Surgeons, 219(4), 713–717. https://doi.org/10.1016/j.jamcollsurg.2014.06.001
Smith, B. A., & Ferguson, D. B. (1991). Disposition of spontaneous pneumomediastinum. The American journal of emergency medicine, 9(3), 256–259. https://doi.org/10.1016/0735-6757(91)90090-7
