https://orcid.org/0000-0002-4893-4991
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Siu Li Boo, Fatemeh Rafati, Mark Pucci, Image: pneumomediastinum following sternutation after cocaine insufflation, Postgraduate Medical Journal, Volume 95, Issue 1123, May 2019, Page 287, https://doi.org/10.1136/postgradmedj-2019-136391
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A 31-year-old man, with no significant medical history, developed sudden onset central chest pain radiating across the upper chest wall and into the neck following sternutation (sneezing). There had been a preceding history of cocaine abuse by insufflation. On clinical examination, there was ulcerated nasal septum, palpable crepitus in the supraclavicular fossae, normal heart sounds and equal air entry to both lungs on auscultation.
His chest radiograph demonstrated bilateral supraclavicular surgical emphysema and pneumomediastinum (figure 1). CT of the thorax confirmed pneumomediastinum with air tracking superiorly into the anterior chest wall, neck and into the skull base without pneumothorax or underlying lung parenchymal disease (figure 2). Urine toxicological analysis confirmed benzoylecgonine, the major metabolite of cocaine.
Pneumomediastinum is defined as the presence of free air in the mediastinum. It is a rare but recognised complication of cocaine abuse, though more commonly associated with inhalation than nasal insufflation.1 The most common symptoms of spontaneous pneumomediastinum are chest pain and dyspnoea. Clinical signs include subcutaneous emphysema and Hamman’s sign, the crepitus heard with the heartbeat on chest auscultation.2
