Case Study: Chest pain radiating into the neck

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Answer: Pneumomediastinum.  Note the additional air column posterior to the tracheal air column, just in front of the vertebral bodies.


Discussion

Pneumomediastinum is a rare condition that can be caused by a trauma or by medical conditions affecting the lungs, esophagus, or nearby structures.  In this case, once the diagnosis was made, it was discovered that the patient had been weightlifting 2 hours before the pain started.  This likely ruptured a small lung bleb.

Symptoms of pneumomediastinum typically include pleuritic chest pain that may also be worse with swallowing.  The pain often radiates to the anterior neck.  Physical examination is usually normal, but on occasion crepitance can be palpated, most frequently in the area of the trapezius.  More rarely, a crunching sound can be heard with each heartbeat.

Testing for pneumomediastinum should include a 2-view chest X-ray.  The lateral view is more sensitive.  Because the air often dissects up into the neck, a lateral neck X-ray could also be performed and could be more sensitive than a 2-view chest X-ray.  If esophageal perforation is suspected, imaging should be conducted to exclude it.

Treatment for spontaneous or Valsalva-induced pneumomediastinum is usually observation and analgesia.  Symptoms usually resolve within a week.  If there has been trauma or esophageal manipulation, then a perforation is diagnosed.  Surgery may be required.

Table 1. Pneumomediastinum, Nontraumatic

General Pleuritic, positional pain that often radiates to neck and is worse with swallowing.
Causes Valsalva, lung dz, dental procedure, trauma, esophageal rupture, ventilator, infection.
Exam Crepitance, often in trapezius area, Hamman's crunch is rare.
Tests Lateral chest and neck XR are more sensitive than frontal CXR. Esophagram if trauma.
Treatment Treat primary cause. If spontaneous: benign, resolves in 2-5 days. Don't fly.

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

  1. Pregerson B. Quick Essentials: Emergency Medicine: The One-Minute Consult—Version 4.0. ERpocketbooks.com; 2010.

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