Patient presented to the ER complaining of worsening cervical pain that had initiated abruptly a few hours ago. He had been diagnosed with Graves disease for about a year with intermittent use of Tapazole. The attending physician initially suspected subacute granulomatous thyroiditis and requested a thyroid ultrasound. 

The findings of the thyroid were compatible with Graves disease, but what stood out were the diffuse echogenic foci with "dirty" shadow suggesting air in the deep neck. This was confirmed by manual palpation during the exam, which showed the characteristic "crackling" on tissue compression. Since the patient had no history of trauma or recent surgical procedure and no other complaints, a spontaneous pneumomediastinum with air dissecting the deep structures of the neck (and causing pain) was the main diagnostic hypothesis.

Follow up CT of the neck and thorax showed a diffuse pneumomediastinum, deep neck and subcutaneous emphysema, without signs of pneumothorax. The patient was hospitalized for a few days and was discharged with clinical improvement.