Case presentation

A 63-year-old male presented to the outpatient department with acute chest symptoms. The patient had complaints of chest pain, chest tightness, and shortness of breath for one day. There was no history of smoking or alcohol consumption and no known comorbidities. The patient was conscious, oriented to time and place, and dyspneic. On examination, the patient was found to have subcutaneous emphysema around the neck and chest progressing to the face and upper limbs, and crepitus extending from the face to the abdomen. No external injuries were found, and Hamman’s sign was present. Heart rate was recorded as 100 bpm, blood pressure 130/90 mmHg, and oxygen saturation was only 85% on room air, which improved to 98% when placed on 12L O2 via a non-rebreather mask (NRBM). The patient had no history of trauma, vomiting, or strenuous activity, and no binge alcohol intake.

The patient was initially evaluated for several differential diagnoses, including Hamman’s syndrome, Boerhaave’s syndrome, pulmonary embolism, pneumothorax, and aortic dissection. Investigations, including electrocardiography (ECG), arterial blood gas (ABG), and complete blood count (CBC), were all found to be normal. The absence of ECG abnormalities and hemodynamic instability reduced the likelihood of pulmonary embolism. Chest X-ray demonstrated pneumomediastinum with subcutaneous emphysema, without evidence of pneumothorax (Figure 1). Boerhaave’s syndrome was considered less likely in view of the absence of vomiting, retching, or alcohol use. Aortic dissection was also considered unlikely as the patient did not have a widened pulse pressure, pulse deficits, or radiological evidence suggestive of dissection. A CT chest was performed to confirm the pneumomediastinum and subcutaneous emphysema. Free air was visualized in the mediastinum on the CT (Figure 2). A diagnosis of spontaneous pneumomediastinum (Hamman’s syndrome) with subcutaneous emphysema was confirmed.

Figure 1: Chest X-ray showing pneumomediastinum with subcutaneous emphysemaPosteroanterior chest radiograph demonstrating extensive pneumomediastinum with arrows representing subcutaneous emphysema involving the cervical and thoracic soft tissues. Additionally, no evidence of pneumothorax is identified.

Figure 2: CT chest showing pneumomediastinumAxial computed tomography (CT) image of the chest, with arrows showing extensive free air within the mediastinum, confirming pneumomediastinum.

The patient was managed with high-flow oxygen via an NRBM and was closely monitored for respiratory distress, with multidisciplinary consultation from Cardiothoracic and Vascular Surgery and Respiratory Medicine. The patient had progressive subcutaneous emphysema involving the face, bilateral upper limbs, and extending to the groin, for which a left-sided intercostal drainage tube was placed. Gradual clinical improvement was noted in the patient, and subcutaneous emphysema resolved within one week. Following the resolution of pneumomediastinum, the patient was discharged in stable condition.