Papers of the Week

Subcutaneous emphysema (SCE) of the head, neck and mediastinum most commonly arises due to penetrating trauma and iatrogenic events facilitating air entry into these spaces [1]. Spontaneous SCE can emerge due to a pressure gradient between the intra-alveolar air and surrounding structures, causing alveolar rupture and dissection of the peribronchovascular sheath. This is known as the Macklin effect. Potential consequences include pneumomediastinum, pneumothorax, facial emphysema and pneumoracchis [1]. We aim to describe a case of SCE in a 21-year-old female presenting to the emergency department (ED) after weight training. A 21-year-old female presented to the ED with a sore throat and dysphagia after weight lifting in the gym 6 h earlier. Training involved repeat Valsalva manoeuvres. She experienced sharp pain with onset over an hour, worse with swallowing. She had a history of gastro-oesophageal reflux disease. Vital signs, local examination and systemic examination were unremarkable. The diagnosis was made with soft tissue neck X-ray, demonstrating emphysema within the prevertebral space extending from the skull base to the first thoracic vertebra (Fig. 1). Her chest X-ray showed no pneumothorax or pneumomediastinum. No intervention was required beyond analgesia, and she was discharged from the ED. She was advised to avoid heavy lifting and diving. A follow-up radiograph showed resolution of the SCE. This case is an important rare entity and highlights for clinicians that pain after physical exercise may involve injuries extending beyond the area directly trained.