A Healthy Young May with Acute Neck Pain

Ahsan Wahab, Siddique Chaudhary, Susan Smith

November 16, 2019

A 19-year-old male, nonsmoker, presented to the emergency department with the acute onset of right-sided neck pain. He described the pain as sharp, mild to moderate in intensity, radiating to the right superior chest, aggravated by deep breathing and the supine position and relieved by analgesics. He denied fever, cough, dyspnea, flu-like symptoms, nausea, vomiting, sore throat, odynophagia and local trauma. On exam, vitals were: BP 132/89 mmHg, pulse 61 beats/minute, temperature 98.70F and oxygen saturation of 98% on room air. He appeared well-nourished and was without signs of acute distress. Oropharynx was normal without erythema, swelling or exudate. Neck was supple and there was no subcutaneous crepitus. On cardiothoracic auscultation, breath sounds were normal and there were no cardiac murmurs. Labs were unremarkable and drug screen was negative for cocaine or cannabinoids. EKG was unremarkable. The patient underwent a CT of the chest with contrast (Figure 1 and Figure 2) which ruled out pulmonary embolism and revealed the diagnosis. He was admitted to the hospital for 24-hour observation and was discharged home the following day. He required no invasive intervention.

Questions:

1.  Based on the history, CT findings and course of illness, what is the most likely diagnosis?

1. Pneumothorax

2. Pneumomediastinum

3. Pneumonia

4. Esophageal Spasm

5. Esophageal Perforation

2.  Which of the following is the most appropriate management for this condition?

1. Analgesics and outpatient follow-up

2. Treatment with antibiotics

3. Prolonged inpatient observation 

4. Upper endoscopy and repair

5. Cardiothoracic Intervention

3.  Which of the following are common examination findings associated with this condition?

1. Use of accessory muscles of respiration

2. Decreased breath sounds

3. Hamman’s sign 

4. Subcutaneous emphysema

5. Both C and D

Answers

1.  B Pneumomediastinum

2.  A Analgesics and outpatient follow up

3.  E Both C and D

Discussion:

Pneumomediastinum is defined as air within the mediastinum and can be divided into primary or secondary causes. Primary or spontaneous pneumomediastinum occurs without hollow viscus perforation or underlying lung pathology. Spontaneous pneumomediastinum and spontaneous pneumothorax are among the most common causes of chest pain in young adults presenting to the hospital. [1] The pathophysiology involves an elevated intrathoracic pressure of the marginal alveoli leading to the escape of air into the surrounding connective tissue sheath and accumulation within the mediastinum, i.e., as pneumomediastinum. Factors that precipitate elevated intrathoracic pressure can lead to this condition; they include smoking, cough, trauma, weight lifting, respiratory tract infections and obstructive airway disease. [2] Dyspnea and chest pain are the two most common symptoms. Physical examination could be normal or reveal subcutaneous emphysema or Hamman’s sign. Hamman’s sign involves a precordial crunching or crackling sound which occurs synchronously with systole. Diagnosis is made by plain radiograph of the chest or by CT scan if plain imaging is negative. The treatment is supportive (oxygen, hydration, analgesics, rest) with 24-48-hour observation. [3] Complications including restrictive lung disease, poor venous return with circulatory failure, air dissection into other body cavities (pericardial tamponade, pneumoperitoneum and pneumoretroperitoneum) and recurrence are uncommon. Extreme cases may require cardiothoracic intervention. 

References:

1. Yellin A, Gapany-Gapanavicius M, Lieberman Y. Spontaneous pneumomediastinum: is it a rare cause of chest pain?. Thorax. 1983;38(5):383-385.2.

2. Halperin AK, Deichmann RE. Spontaneous pneumomediastinum: a report of 10 cases and review of the literature. N C Med J. 1985;46(1):21-23.

3. Takada K, Matsumoto S, Hiramatsu T, et al. Management of spontaneous pneumomediastinum based on clinical experience of 25 cases. Respir Med. 2008;102(9):1329-1334.

Authors (Up to date at time of submission):

Dr. Ahsan Wahab is an Internal Medicine Resident in McLaren Flint –Michigan State University Residency Program in Flint, Michigan. He was born in Pakistan and wants to pursue a career in the field of Internal Medicine.

Dr. Siddique Chaudhary graduated from Services Institute of Medical Sciences Pakistan in 2013. He is currently working as a scheduling chief in the Internal Medicine Department of McLaren Flint-Michigan State University Residency Program. Dr. Chaudhary is pursuing a career in Pulmonary and Critical Care Medicine. 

Dr. Susan J Smith is the former Program Director at McLaren Flint –Michigan State University. She has participated in many scholarly activities involving Internal Medicine Residents.