A diagnostic challenge of an unusual presentation of pneumomediastinum

A 77-year-old man who had underwent orthopedic surgery 17 days ago due to his left femur frac- ture caused by a pedestrian-car accident came to our emer- gency department with the chief complaint of a 2 days his- tory of sore throat and cough and also swelling of eyelids. He had no respiratory distress or any other life-threatening symptoms. Subsequent physical examination revealed re- markable edema and crepitus over the whole face, neck, proximal upper limbs and the anterior and posterior chest regions, and also bilateral hyperresonance was detected in pulmonary auscultation. The imaging studies showed pneu-momediastinum and bilateral subcutaneous emphysema. The diagnosis of pneumomediastinum and mild left pneumotho- rax and massive subcutaneous emphysema was definitely made. He underwent bilateral tube thoracostomy by using a 32 French chest tube under local anesthesia in the fifth in- tercostal space on the anterior axillary line. The patient was discharged with no complications 10 days postoperatively.