A 16-year-old healthy male adolescent presented in the Emergency Department with right pleuritic chest pain extending to neck, that started suddenly seven hours before admission, without previous history of trauma or other symptoms.
Physical examination was unremarkable, except for the presence of localised tenderness inflicted by palpation of the 2
nd and 3
rd right intercostal spaces and ipsilateral sternocleidomastoid muscle. Chest radiography revealed a right linear lucency outlining mediastinal contours, of inconclusive nature. (Figure 1) The resting electrocardiogram was normal for age. On the first day of admission, a swelling and subcutaneous emphysema were noted on the right sternal border between 2
nd/3
rd intercostal spaces. The chest ultrasound showed the presence of air bubbles in the intermuscular spaces. The Computed Tomography (CT) Scan of chest and neck confirmed the presence of air distributed bilaterally in the mediastinum, mainly on the right side and extending to the neck and dissecting the anatomical planes of the upper mediastinum. (Figure 2)
Figure 1. Posteroanterior plain chest radiograph showing right linear lucency outlining mediastinal contours (arrow).
Figure 2. Patient chest computed tomography scan shows presence of interstitial air distributed bilaterally in the mediastinum, mainly on the right side and extending to the neck, and dissecting the anatomical planes of the upper mediastinum (arrows).
What is the diagnosis?