Vomiting, diarrhea and stiff neck: What is your call?

Discussion

The answer is (b) spontaneous retropharyngeal emphysema, a diagnosis of exclusion that is most often associated with a pneumomediastinum. Air dissects through tissue planes from the mediastinum into the neck.1 Causes of the condition include explosive coughing, singing, weight lifting, labour and vomiting, all of which increase intrathoracic pressure.2 Patients usually present with dysphagia, sore throat and neck pain. Physical examination may reveal subcutaneous emphysema in the neck and chest. If there is also pneumomediastinum, the patient may have dysphonia and retrosternal pain on examination, and Hamman sign (a crunching sound heard over the chest in cases of mediastinal emphysema). Hamman sign is classically described during systole and is often transient.3

Conservative treatment, including bed rest, observation, analgesia and therapy with 100% oxygen to increase the resorption gradient for nitrogen, is often sufficient.4 With this treatment, most cases resolve within 5 to 7 days depending on the severity of injury. Therapy with 100% oxygen is most useful when patients have respiratory distress or discomfort. Antibiotics are not needed unless there are signs of infection.

Differential diagnosis: Although spontaneous retropharyngeal emphysema is usually a benign process with a good prognosis, other causes of retropharyngeal emphysema should be ruled out (Table 1). These causes, including infection, trauma caused by intubation or foreign-body ingestion and esophageal perforation (Boerhaave syndrome), require further investigation with contrast studies, endoscopy, or urgent surgical consultation and intervention.

Boerhaave syndrome, a spontaneous perforation of the esophagus, was first described in 1724.5 This syndrome must be ruled out before a diagnosis of spontaneous retropharyngeal emphysema can be made. In our patient's case, we performed contrast studies that showed no esophageal perforations.

Retropharyngeal emphysema can result from an infectious process in the retropharyngeal area, such as retropharyngeal abcess.6 Clinical signs, such as fever or leukocytosis, can be helpful in making this diagnosis. Also, neck imaging may reveal a thickened retropharyngeal space.

A history of traumatic penetrating injury from such causes as foreign-body impaction, intubation or esophageal instrumentation helps to guide further investigations, including contrast studies.6