Teenager with chest pain and swollen neck: a leave-it-alone condition

Abstract

A 19-year-old boy with shortness of breath and chest pain after strenuous exercise presented to emergency department . On physical examination, the neck and shoulders appeared to be swollen. There was crepitus on skin palpation. Chest X-ray disclosed diffuse subcutaneous emphysema and pneumomediastinum. CT showed additional finding of air in epidural space. The patient was discharged after 2 days of hospitalisation with conservative treatment uneventfully. Pneumorrhachis is usually caused by abrupt increase in intrathoracic pressure in instance of forceful vomiting, cough or asthma attack in an otherwise healthy young adult. It is usually accompanied with pneumomediastinum. The management of epidural pneumatosis should be tailored according to its primary cause. For most patients with pneumorrhachis associated to a spontaneous pneumomediastinum without neurological symptoms, this condition is generally self-limited. For epidural free air of large volume that causes neurological deficits, surgical laminectomy may be indicated.

Spontaneous Pneumorachis – A Case-Based Review

“…The most common presenting complaint is retrosternal, pleuritic chest pain radiating to the neck or shoulders of acute onset after an inciting event. 67 , 68 Even when no triggering factor is present, SPM should be considered in the differential diagnosis of any young adult presenting with acute onset chest pain. 69 , 70 Other common symptoms include subcutaneous emphysema with crepitus, especially in the neck, neck pain, dyspnea, cough, odynophagia, and dysphagia.…”

“… No Discharged but died 3 months later from cancer progression 25 Krishnan et al( 20 ) 30/M Unknown Unknown Subcutaneous emphysema, pneumomediastinum Subcutaneous incisions, symptomatic medications No Discharged 26 Jensen et al( 9 ) Unknown Anorexia nervosa Bouts of self induced vomiting Unknown Conservative medical approach and treatment of anorexia nervosa Unknown Unknown 27 Moayedi et al( 28 ) 76/f Multiple sclerosis, diabetes mellitus Sacral decubitus ulcer Pneumocephalus, subcutaneous emphysema IV antibiotics - cefepime, metronidazole; levetiracetam Yes Passed away 6 days later from sepsis after being made comfort measures 28 Martins et al( 5 ) 20/m, 22/m None Acute bout of dry cough. Pneumomediastinum, subcutaneous emphysema Bedrest, oxygen, and opioids for cough control No Discharged 29 Liao et al( 68 ) 19/m None Strenuous exercise Subcutaneous emphysema, pneumomediastinum Conservative treatment No Discharged 30 Eisa et al( 84 ) 18/m None …”

Clearing the air around spontaneous pneumorrhachis

“…[3] The underlying pathophysiology is postulated to be increased intra-alveolar pressure (for example, excessive prolonged coughing, forceful vomiting, asthma, etc. [4] ), leading to rupture of alveoli, due to which air travels along the pulmonary perivascular interstitium and dissects along the fascial planes. [5] As the pressure in the mediastinum is lower than the lung periphery, the air dissects toward the hilum of the lung and leads to pneumomediastinum.…”

Spontaneous pneumomediastinum and subcutaneous emphysema in a child with unknown aetiology

“…The common causes of secondary SPM were asthmatic exacerbation, pneumonia or lower respiratory tract infections, or choking. Teenager with chest pain and swollen neck: a leave-it-alone condition9 describes a 19 year old with subcutaneous emphysema pneumomediastinum and air in the epidural space. The patient was treated conservatively.…”