Cervical emphysema due to spontaneous pneumomediastinum (Hamman syndrome)

Case contributed by Dr Manuel Schütze

Presentation

Worsening cervical pain that initiated abruptly a few hours ago. History of Graves disease with intermittent use of Tapazole. There was no history of trauma or recent surgical procedures. Patient is a smoker.

Patient Data

Age: 25 years
Gender: Male

The ultrasound shows an enlarged and heterogeneous thyroid, with increased flow on Doppler imaging, compatible with the diagnosis of Graves disease. There were no signs suggestive of subacute granulomatous thyroiditis. There were diffuse echogenic foci with a "dirty" shadow surrounding vessels and muscles of the neck and also the posterior wall of the thyroid, suggesting air in the deep neck.

The chest and neck CT shows pneumomediastinum, deep neck and subcutaneous emphysema.

Case Discussion

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.

PlayAdd to Share

Case information

rID: 72299
Published: 23rd Nov 2019
Last edited: 23rd Nov 2019
Inclusion in quiz mode: Included
Institution: Hospital MaterDei

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.