A 16-Year-Old Female with Neck Pain After Swallowing

Differential Diagnosis

• Deep neck infection
• Retained foreign body
• Pediatric epiglottitis
• Retropharyngeal gas

Diagnosis

The source of this patient’s discomfort is retropharyngeal gas due to local perforation of the upper esophagus.

Learnings and What to Look for

• Retropharyngeal air can be caused by local perforation to the aerodigestive tract or due to tracking air from the chest secondary to pneumomediastinum
• Neck radiographs are not necessarily recommended in the evaluation of oro-esophageal trauma but can be utilized to evaluate for radio-opaque foreign bodies or to evaluate for deep neck infections such as retropharyngeal abscess or epiglottitis
• Contrast swallow under fluoroscopy is a preferred study to exclude an esophageal or pharyngeal leak; however, computed tomography angiography (CTA) is the preferred study to evaluate for air leak, foreign body, and vessel injury, especially in the case of penetrating trauma to the posterior oropharynx
• Patients with retropharyngeal air may present with “hot potato” voice if it leads to upper airway obstruction, similar to epiglottitis

Pearls for Urgent Care Management

• In cases of spontaneous pneumomediastinum, the management is supportive, and definitive care can generally be provided in the urgent care center. It is recommended to treat the underlying cause (eg, asthma, vomiting, etc.) and evaluate for signs of hemodynamic instability and progression, although this is rare
• In cases of esophageal leak, consultation with a specialty center is necessary to guide acute management
• Hot potato voice or other signs of upper airway obstruction necessitate emergent transfer

Acknowledgment: Images and case presented by Experity Teleradiology (www.experity.com/teleradiology).