Sore throat in a young man: guess what…

Abstract

Sore throat is a common complaint in the outpatient and emergency room settings. Typically, little workup is necessary and includes visual inspection with or without swabs for bacterial infection. We present a case that demonstrates an important entity to be excluded by simple history and physical examination in patients presenting with pain in the throat or neck. The most important cause of pneumomediastinum is previous instrumentation. Spontaneous pneumomediastinum is uncommonly seen in young adults. Most cases of spontaneous pneumomediastinum are uncomplicated, as mediastinal pressures rarely mount to dangerous levels. However, when the patient presents with distended neck veins, cyanosis or marked dyspnoea, further action is necessary. Lastly, since pneumomediastinum can be caused by oesophageal rupture and occasionally present with concurrent pneumothorax, these dangerous entities must be excluded.

Background

Sore throat is a common complaint in the outpatient and emergency room settings. Typically, little workup is necessary and includes visual inspection with or without swabs for bacterial infection. We present a case that demonstrates an important entity to be excluded by simple history and physical examination in patients presenting with pain in the throat or neck.

Case presentation

This is a case of a 26-year-old man with a medical history significant only for HIV (on antiretroviral therapy, CD4 count 1223, viral load undetectable) presenting to the ER with a chief complaint of sore throat for 1 day. He denied fevers, chills or dysphagia during this interval, but noted that his sore throat was associated with visible external swelling of the neck and a vague sensation of bubbles in his neck and chest wall. He also complained of mild chest pain on deep inspiration and occasional dyspnoea. He denied any history of trauma or recent instrumentation of the upper airway. The patient had smoked methamphetamine the day prior. He reported excessive straining during bowel movements. On presentation, he was in no acute distress and displayed stable vital signs. Physical examination showed mildly injected oropharynx, palpable crepitus of the left anterior neck and chest wall, and precordial crackles heard best in the left lateral decubitus.

Investigations

Radiographs showed upper chest wall, retropharyngeal and prevertebral emphysema, as well as pneumomediastinum (figure 1). Chest CT showed extensive pneumomediastinum with lack of evidence for pneumothorax or oesophageal rupture (figures 2 and 3). Neck CT showed extensive pneumomediastinum, contiguous with air in the soft tissues of the deep neck; this is seen in the prevertebral soft tissues and parapharyngeal spaces, as well as a small amount in the spinal canal (figure 4).

Figure 1.

Chest X-ray.

Figure 2.

Chest CT1.

Figure 3.

Chest CT2.

Figure 4.

Neck CT.

Outcome and follow-up

He was observed for 24 h and discharged with oral analgesics.

Discussion

The most important cause of pneumomediastinum is previous instrumentation.¹ Spontaneous pneumomediastinum is uncommonly seen in young adults. Spontaneous pneumomediastinum most commonly occurs after severe asthma exacerbations, during which excess coughing pressure ruptures small alveoli, allowing air to leak into the bronchovascular sheath of the relatively low-pressure mediastinum. Cardiac auscultation will reveal a precordial crackle, heard best in the left lateral decubitus position (Hamman's sign).² Air often spreads further into the subcutaneous neck and thorax, resulting in palpable crepitus. Spontaneous pneumomediastinum is known to rarely occur after use of inhaled methamphetamine, which requires the user to take a deep inspiration followed by a Valsalva manoeuvre and secondary coughing, potentially causing alveolar rupture. In this case report there was extensive subcutaneous emphysema and spontaneous pneumomediastinum following ingestion of ecstasy.³ This patient's straining during bowel movements may have precipitated his condition.

Learning points.

• Most cases of spontaneous pneumomediastinum are uncomplicated, as mediastinal pressures rarely mount to dangerous levels. However, when a patient presents with distended neck veins, cyanosis or marked dyspnoea, further action is necessary. Lastly, since pneumomediastinum can be caused by oesophageal rupture and occasionally present with concurrent pneumothorax, these dangerous entities must be excluded.