Presentation
Respiratory distress, hypoxic. Known emphysema with bullous disease.
Patient Data
Initial CXR on presentation
Large right pneumothorax, with mediastinum shift to the left, suggestive of a tension pneumothorax. The right upper lobe appears adherent to the pleura at the apex.
Post-insertion of small-bore intercostal catheter. Pneumothorax remains unchanged.
The patient developed severe subcutaneous emphysema involving bilateral chest wall and tracking up the neck. The Ginkgo leaf sign of subcutaneous emphysema is well demonstrated.
A second large-bore intercostal catheter was inserted, resulting in significant clinical and radiological improvement of the pneumothorax.
X-ray neck/upper chest
Subcutaneous emphysema of chest wall tracking up the neck.
Interval imaging on day of discharge confirms resolution of right pneumothorax and removal of both intercostal catheters. Residual subcutaneous emphysema is present but clinically this had significantly improved.
Case Discussion
This case demonstrates a tension pneumothorax and post-intercostal catheter severe subcutaneous emphysema. The patient was successfully managed with two intercostal catheters on suction and a short stay in the intensive care unit followed by a period of close observation on the ward.
The Ginkgo leaf sign is radiologically apparent when there is severe subcutaneous emphysema of the chest wall, resulting in the striations of the pectoralis major muscle being well defined by adjacent air.
Case courtesy of Dr Drusilla Poiner, The Prince Charles Hospital, Queensland, Australia.
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