Massive subcutaneous emphysema and pneumomediastinum as a presentation of foreign body aspiration

We describe an uncommon clinical case of unrecognized foreign body aspiration presented with sudden onset of facial swelling as a result of massive subcutneus emphysema and pneumomediastinum.
This is an instructive case, with interesting and misleading presenting symptoms, that emphasize the importance of the medical interview and physical examination, especially in the emergency department (ED). We described the work-up of a young child, presented with symptoms resembling an allergic reaction, which led to the working diagnosis of anaphylactic reaction and therefore treated accordingly.

This clinical case highlights the importance of a methodological approach for young physicians. In this clinical case we also review the full diagnostic process along with several imaging modalities of his massive pneumomediastinum and subcutaneous emphysema. Interestingly, although this child had massive air leak to the soft tissues, no pneumothorax was noted at the CT or the chest x ray. This is a rare finding, especially in foreign body aspiration, where the mechanism is an abnormal rise in intra-alveolar pressure leading to alveolar rupture.

We will review the literature on air leaks in children, specifically as a presentation of foreign body aspiration.