A never-smoking 22-year-old male with no past medical history presented to the emergency department with sudden onset of sharp central chest pain and right-sided neck discomfort. There was no history of trauma or bronchitis. There was no history of air travel, allergen exposure or illicit drug use. He had consumed alcohol the night before presentation but had not vomited.
Clinically, he had right-sided subcutaneous emphysema but no signs of pneumothorax. His pulse was 82 beats per min, blood pressure was 134/76 mmHg and oxygen saturation was 98% on air. His blood tests revealed no abnormality. His blood alcohol level was not measured.
Chest radiography.
Task 1
Interpret the chest radiograph (fig. 1)
Answer 1
The chest radiograph (fig. 1) shows right-sided subcutaneous emphysema in the neck and a pneumomediastinum (PM) with air tracking in the muscle planes of the neck but no pneumothorax.
At presentation, a diagnosis of oesophageal rupture was considered but an upper gastrointestinal endoscopy was normal. Contrast-enhanced helical computed tomography (CT) of the thorax and upper abdomen was performed (figs 2–5).
Contrast-enhanced helical CT.
Contrast-enhanced helical CT.
Contrast-enhanced helical CT.
Contrast-enhanced helical CT.
Task 2
Interpret the CT images (figs 2–5)
Answer 2
The CT images show extensive subcutaneous emphysema on the right, extensive PM outlining the vessels with air, and air …
