Case of the Week 97 Courtesy of Serafin Leemann, DC 32 year old female presented with swallowing difficulty. Her ROM of the neck was almost normal and she complained of anterior neck 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 this be managed?

Answers MOST significant findings: DDX: Management: Multiple linear streaks of air are visualized in the prevertebral soft tissues and subcutaneous area anteriorly as well as in the soft tissues lateral to the cervical spine and upper thoracic spine. Air is faintly seen outlining the descending aorta and on the right side of the mediastinum. DDX: The DDX must first exclude serious pathology such as perforation of the esophagus, bronchi or a penetrating chest injury. Abscess is another DDX. When these are ruled out, then this is most likely a spontaneous ‘Pneumomediastinum’ due to alveolar rupture from things such as asthma or baro-trauma. Management: Immediate referral is indicated (and was done) for CT.

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

Coronal soft tissue window CT slices also showing the abnormal air

Axial CT mediastinal chest windows showing the numerous pockets of mediastinal air, confirming that this is pneumomediastinum. The arrows show some of these.

Follow-up No evidence of perforation was found and the patient had no symptoms of infection. Infection should also be more localized. Because she is a singer, this is likely to be spontaneous pneumomediastinum due to increased pressure in her chest from singing. At her second chiropractic visit she was already much improved. There is no treatment for this and the air will be reabsorbed.