Unexplained Recurrent Subcutaneous Emphysema of the Face,Neck,and Mediastinum in an Otherwise Healthy Adult

Abstract

Objectives:

1) Understand the presentation and work-up of a rare cause of recurrent, diffuse subcutaneous emphysema in the head and neck. 2) Apply the findings from this case report and related literature.

Methods:

We describe a case of a 23 year-old man who presented to the Emergency Department at a tertiary care center complaining of an acute onset of diffuse swelling throughout his face, neck, and chest.

Results:

The full diagnostic work-up for this patient included routine laboratory studies, computed tomography (CT) imaging of the head, neck, and chest, fluoroscopic esophagram, and prior esophagogastroduodenoscopy and bronchoscopy. Thoracic and otolaryngology consultations were sought. The patient demonstrated a leukocytosis and severe, diffuse subcutaneous emphysema throughout the face, neck, and mediastinum visible on CT imaging. The remaining work-up was negative for organic causes. Several small, inconspicuous wounds were noticed on the patient’s right cheek and buccal mucosa, consistent with self-inflicted needle injuries. It was determined that the patient had intentionally created percutaneous facial and neck defects with a needle and expired against a closed glottis to create the observed symptoms. A psychiatry consultation was sought, and the patient was discharged shortly thereafter in stable condition. A review of the literature suggests that this factitious etiology of subcutaneous emphysema is quite rare and emphasizes the importance of the physical exam the consulting otolaryngologist may employ when evaluating new patients.

Conclusions:

Factitious subcutaneous emphysema in the United States is a rare, seldom reported finding in the otolaryngology literature but may be suspected when the patient has a prior history of psychiatric disorder or self-harm and work-up for organic causes is negative.