Case contributed by Emily Mulder
Diagnosis almost certain


Four days of worsening sore throat, cough, and muffled voice.

Patient Data

Age: 20 years
Gender: Female

CT soft tissue neck C+


Bilateral tonsillar enlargement is noted with an increase in vascularity.  A 23.5 x 18.3 x 31.1 mm rim-enhancing fluid collection is noted in the right tonsil and a 16.1 x 16.5 x 21.4 mm rim-enhancing fluid collection is noted in the left tonsil.  There is associated mild narrowing of the nasopharyngeal airway.

Superior pneumomediastinum with superior extension in the cervical fasciae is noted. The larynx and trachea are normal.  The parotid, submandibular and thyroid glands appear normal.  No mass or lymphadenopathy is seen.  The visible paranasal sinuses, mastoid air cells and middle ear cavities are normally aerated.  The skeletal structures and vasculature are normal.  The visualized intracranial structures are normal.

Frontal Chest Xray


There is moderate pneumomediastinum. Lung volumes are adequate. No consolidation is present. Pulmonary vasculature is normal. No pneumothorax or pleural effusion is identified. Regional bones and soft tissues are within normal limits.

Case Discussion

This patient with bilateral tonsillitis with bilateral tonsillar/peritonsillar abscesses was diagnosed with pneumomediastinum and cervical subcutaneous emphysema. These findings could be related to actions that increase pressure in the airway/lungs, such as violent coughing or vomiting, or Valsalva maneuver. These findings prompted an esophagram, from which the esophagus was found to be intact and without perforation. No definitive cause was found, though the most likely cause was thought to be benign pneumomediastinum secondary to coughing.

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