Adult Male With Neck Discomfort

Robert Hoffman
New York City Poison Center
New York, NY

Int J Med Toxicol 1998; 1(4): 20

These case conferences are supported by a grant from Orphan Medical, Inc.

See also NEW CASE - SUMMARY  - 1998; 1(4): 17

Pneumothorax, pneumomediastinum, pneumopericardium, and pneumoperitoneum all occur following substance abuse. While most recent reports are attributed to smoking crack cocaine, insufflation of cocaine or heroin, smoking marijuana, and inhaling nitrous oxide have all been associated with these findings. Because of the diverse nature of the toxins involved, it must be concluded that the development of a "pneumo" is not a manifestation of direct drug toxicity, but rather of barotrauma resulting from direct use of a high pressure cylinder (nitrous oxide), prolonged Valsalva maneuvers, or an attempt to inflate the lungs beyond their capacity.

Patients typically present with neck, chest, or abdominal pain, or difficulty swallowing, but are also occasionally asymptomatic only to be discovered by routine radiographic studies. As seen in the AP chest radiograph presented here, there is a prominence of air in the soft tissues of the neck and chest. The CT scan demonstrates air in the mediastinum (best seen posterior to the heart).

Treatment varies with location of the air leak and size. It is important to remember that these events commonly occur as manifestations of trauma, which is often occult in substance abusers so that a thorough history and physical examination is usually required. Pneumoperitoneum is usually evaluated surgically, while pneumomediastinum and pneumopericardium are typically observed. Small pneumothoraces can be observed, while large ones are treated with needle aspiration or chest tube. This patient was followed over several weeks with complete resolution of radiographic findings.


  1. Berro E, Mehta J, Dralle WM, Williams J: "Ring around the artery" as a presenting feature in undiagnosed asthma with pneumomediastinum. South Med J 1990 Feb;83(2):215-217.
  2. Conway EE Jr: Spontaneous pneumomediastinum [letter]. Chest 1992;101:1743.
  3. Eurman DW, Potash HI, Eyler WR, Paganussi PJ, Beute GH: Chest pain and dyspnea related to "crack" cocaine smoking: value of chest radiography. Radiology 1989;172:459-462.
  4. Fajardo LL: Association of spontaneous pneumomediastinum with substance abuse. West J Med 1990;152:301-304.
  5. Leitman BS, Greengart A, Wasser HJ: Pneumomediastinum and pneumopericardium after cocaine abuse [letter]. Am J Roentgenol 1988;151:614.
  6. Onwudike M: Ecstasy induced retropharyngeal emphysema. J Accid Emerg Med 1996;13:359-361.
  7. Palat D, Denson M, Sherman M, Matz R: Pneumomediastinum induced by inhalation of alkaloidal cocaine. N Y State J Med 1988;88:438-439.
  8. Pollack A, Lask P, Kassner EG, Wood BP: Radiological case of the month. Retrocardiac pneumomediastinum. Am J Dis Child 1992;146:831-832.
  9. Riccio JC, Abbott J: A simple sore throat? Retropharyngeal emphysema secondary to free- basing cocaine. J Emerg Med 1990;8:709-712.
  10. Seaman ME: Barotrauma related to inhalational drug abuse. J Emerg Med 1990;8:141-149.
  11. Sullivan TP, Pierson DJ: Pneumomediastinum after freebase cocaine use. Am J Roentgenol 1997;168:84.
  12. Uva JL: Spontaneous pneumothoraces, pneumomediastinum, and pneumoperitoneum: consequences of smoking crack cocaine. Pediatr Emerg Care 1997;13:24-26.


Int J Med Toxicol 1998; 1(4): 20

This article is located at

Quick Survey
Please rate this article:
1 2 3 4 5
(5 is best)

IJMT Home | Current Issue | Past Issues | Search | Technical Support | Send Comments to ACMTNet

Copyright 1999-2003, American College of Medical Toxicology.