A 72-year-old female presented by ambulance with severe difficulty in breathing and facial swelling, initially attributed to anaphylaxis caused by taking ibuprofen. Further questioning revealed she had slipped in the bathroom and hit her back prior to requiring analgesia. Past medical history included Chronic Obstructive Pulmonary Disease (COPD) and dementia.

On examination, she had marked facial swelling but no airway compromise. She was tachypnoeic with unrecordable saturations on high-flow oxygen. On palpation, she had widespread subcutaneous emphysema from her face to her ankles, with minor fresh bruising over her right lower ribs.

Chest radiograph confirmed extensive subcutaneous emphysema with obscured lung fields (figure 1). A right-sided chest drain was inserted and the patient stabilised. CT scan showed pneumomediastinum with a now-expanded right lung and a left-sided pneumothorax (figure 2). There was no evidence of oesophageal or tracheal injury. A second chest drain was inserted and the patient was admitted to the ward in a stable condition. Pneumomediastinum is most commonly caused by trauma or mechanical ventilation. Spontaneous pneumomediastium can occur, particularly in those with underlying lung disease. Air tracking from the mediastinum along bronchovascular sheaths can lead to pneumothoraces and subcutaneous emphysema, though rarely as extensively as in our case.¹

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Figure 1

AP erect chest radiograph showing widespread subcutaneous emphysema.

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Figure 2

CT of the thorax showing pneumediastinum (white arrow), left sided pneumothorax (arrow head), right sided chest drain (curved arrow) and subcutaneous emphysema (black arrow).