American Journal of Emergency Medicine (2011) 29, 959.e3959.

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www.elsevier.com/locate/ajem

Case Report
Occult Pneumothorax on Chest X-ray
Abstract
We report the case of an adult woman who presented to
the medical emergency department because of a swollen
neck, eye lid, and chest pain. Vital signs were normal except
for tachycardia; a trauma was denied. Clinical examination
was remarkable for crepitation on the neck and thoracic wall
indicating subcutaneous emphysema. The chest radiograph
confirmed extensive emphysema; and a computed tomography scan diagnosed pneumothorax on both sides invisible on
conventional radiography with gas in the soft tissue of the
neck, chest, and abdominal wall. Pneumothorax may not be
detectable in standard chest x-ray, may cause unspecific
symptoms, and can occur even after minor trauma.
A 57-year-old woman without preexisting conditions
presented to the emergency department because of pain in the
neck, the left eye lid, and the chest. Blood pressure, respiratory
rate, and pulse oximeter oxygen saturation were within the
reference range; but sinus tachycardia of 131/min was seen.
The patient was well oriented, and communication was possible
without restrictions. A trauma or dyspnea was denied.
Clinical examination was remarkable for crepitation on the
neck and thoracic wall indicating subcutaneous emphysema.
The chest radiograph confirmed extensive emphysema
(Fig. 1A, B) caused by a rib fracture (Fig. 1A). Computed
tomography scan diagnosed pneumothorax (Fig. 1C) invisible on conventional radiography with gas in the soft tissue of
the neck, chest, and abdominal wall (Fig. 1C and D).
Laboratory examinations revealed an elevated serum alcohol
level (2.3).
Consecutively, the patient was treated with thoracocentesis and bilateral thoracic suction tubes. She was discharged
in good health and complete remission of the emphysema on
the ninth postoperative day.

0735-6757/$ see front matter 2011 Elsevier Inc. All rights reserved.

Subcutaneous emphysema in the emergency department is

associated with a variety of diseases including pneumothorax
and necrotizing fasciitis [1]. As in our case, anteroposterior
chest radiography may fail to diagnose pneumothorax,
whereas computed tomography and ultrasound are more
sensitive imaging modalities [2,3]. Occult pneumothorax can
occur even after minor trauma not always evident upon
clinical history and may cause unspecific symptoms.
Karin Amrein MD
Harald Sourij MD
Julia Mader MD
Department of Internal Medicine
Medical University of Graz
A-8036 Graz, Austria
E-mail address: karin.amrein@medunigraz.at
Steven Amrein MD
Department of Anesthesiology
Medical University of Graz
A-8036 Graz, Austria
Tanja Robl MD
Department of Radiology
Medical University of Graz
A-8036 Graz, Austria
doi:10.1016/j.ajem.2010.07.025

References
[1] Marti de Gracia M, et al. Subcutaneous emphysema: diagnostic clue in
the emergency room. Emerg Radiol 2009;16(5):343-8.
[2] Ball CG, Kirkpatri ck AW, Feliciano DV. The occult pneumothorax:
what have we learned? Can J Surg 2009;52(5):E173-9.
[3] Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad
Emerg Med 2003;10(1):91-4.

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Case Report

Fig. 1 A and B, Extensive cervical, thoracal, and upper abdomen subcutaneous emphysema (white arrows) due to a recent fracture of the
seventh rib on the right side (black arrow). No definable pneumothorax. Osteosynthetic material in the thoracal spine. C, Computed
tomography of the thorax, lung window: distinctive emphysema (black arrows). Mediastinal emphysema and narrow pneumothorax on the
right side (white arrows). D, Computed tomography of the skull and neck, sagittal multiplanar reconstruction, lung window: extensive soft part
emphysema of the neck and craniofacial muscles (black arrows).