Case of the Week 97Case of the Week 97Courtesy of Serafin Leemann, Courtesy of Serafin Leemann,

DCDC32 year old female presented with swallowing 32 year old female presented with swallowing difficulty. Her ROM of the neck was almost difficulty. Her ROM of the neck was almost normal and she complained of anterior neck normal and she complained of anterior neck

pain. She is a singer and actress.pain. She is a singer and actress.

What are the MOST significant abnormal findings? What are the MOST significant abnormal findings? What is the Differential Diagnosis? How should What is the Differential Diagnosis? How should

this be managed?this be managed?

AnswersAnswers MOST significant findings:MOST significant findings:

Multiple linear streaks of air are Multiple linear streaks of air are visualized in the prevertebral soft visualized in the prevertebral soft tissues and subcutaneous area tissues and subcutaneous area anteriorly as well as in the soft anteriorly as well as in the soft tissues lateral to the cervical spine tissues lateral to the cervical spine and upper thoracic spine. and upper thoracic spine.

Air is faintly seen outlining the Air is faintly seen outlining the descending aorta and on the right descending aorta and on the right side of the mediastinum.side of the mediastinum.

DDX:DDX: The DDX must first exclude The DDX must first exclude

serious pathology such as serious pathology such as perforation of the esophagus, perforation of the esophagus, bronchi or a penetrating chest bronchi or a penetrating chest injury. Abscess is another DDX. injury. Abscess is another DDX. When these are ruled out, then When these are ruled out, then this is most likely a spontaneous this is most likely a spontaneous ‘Pneumomediastinum’ due to ‘Pneumomediastinum’ due to alveolar rupture from things such alveolar rupture from things such as asthma or baro-trauma.as asthma or baro-trauma.

Management:Management: Immediate referral is indicated Immediate referral is indicated

(and was done) for CT.(and was done) for CT.

Note the multiple streaks of air in the soft tissues Note the multiple streaks of air in the soft tissues (as distinguished from the normal pharynx and (as distinguished from the normal pharynx and

trachea).trachea).

Coronal soft tissue window CT slices also showing Coronal soft tissue window CT slices also showing the abnormal airthe abnormal air

Axial CT mediastinal chest windows showing the numerous Axial CT mediastinal chest windows showing the numerous pockets of mediastinal air, confirming that this is pockets of mediastinal air, confirming that this is

pneumomediastinum. The arrows show some of these.pneumomediastinum. The arrows show some of these.

Follow-upFollow-up

No evidence of perforation was found and the No evidence of perforation was found and the patient had no symptoms of infection. Infection patient had no symptoms of infection. Infection should also be more localized. should also be more localized.

Because she is a singer, this is likely to be Because she is a singer, this is likely to be spontaneous pneumomediastinum due to spontaneous pneumomediastinum due to increased pressure in her chest from singing. At increased pressure in her chest from singing. At her second chiropractic visit she was already her second chiropractic visit she was already much improved.much improved.

There is no treatment for this and the air will be There is no treatment for this and the air will be reabsorbed. reabsorbed.