A 52-year-old male presented to the emergency department with left eye swelling. Imaging revealed he had spontaneous idiopathic pneumomediastinum with unilateral subcutaneous emphysema tracking from his mediastinum to his left eye. This is a rare presentation of pneumomediastinum, with only one previous case report describing pneumomediastinum presenting with unilateral periorbital emphysema. He was admitted overnight for observation and discharged the next day when his symptoms improved.

1. Case Report
Pneumomediastinum presenting as left periorbital
subcutaneous emphysema
Abstract
Idiopathic spontaneous pneumomediastinum is rare but even rarer
is associated unilateral periorbital subcutaneous emphysema. There is
only 1 known case report noting both of these findings and was associ-
ated with endoscopic retrograde cholangiopancreatography complica-
tion [1,2]. Isolated periorbital emphysema has been associated with
dental procedures [3], facial trauma, and sneezing [4]. It is has also
been seen with pneumomediastinum caused by barotrauma, pneumo-
thorax, endoscopic retrograde cholangiopancreatography, and esopha-
geal perforation. A 52-year-old White male presents to the emergency
department with complaint of left eye swelling that occurred overnight
without known cause. He was found to have spontaneous idiopathic
pneumomediastinum and unilateral periorbital subcutaneous emphy-
sema. Although rare, it is important to rule out subcutaneous air track-
ing from pneumomediastinum when evaluating unilateral periorbital
swelling in an otherwise asymptomatic patient.
Idiopathic spontaneous pneumomediastinum is rare but even rarer
is associated unilateral periorbital subcutaneous emphysema. There is
only 1 known case report noting both of these findings and was associ-
ated with endoscopic retrograde cholangiopancreatography complica-
tion [1,2]. Isolated periorbital emphysema has been associated with
dental procedures [3], facial trauma, and sneezing [4]. It is has also
been seen with pneumomediastinum caused by barotrauma, pneumo-
thorax, endoscopic retrograde cholangiopancreatography, and esopha-
geal perforation.
A 52-year-old White male presents to the emergency department
with complaint of left eye swelling that occurred overnight (Fig. 1). The
patient states that he woke up in the morning, and when he looked in
the mirror, his left periorbital soft tissue was swollen. He does not recount
any allergic insult. He denies visual disturbance or pain. He has no fever,
no rash, and no arthropathy. He denies chest pain, shortness of breath,
or wheezing. He does have a chronic cough from smoking cigarettes.
His vital signs are normal except a blood pressure of 179/90 mm Hg.
Patient has a medical history of tobacco abuse, alcohol abuse, high
blood pressure, and rare visits to his primary care doctor. The patient
does not have any known allergies or surgical history. He lives alone
and drives a truck for a living.
On examination, he is a well-developed man of average height lying
supine in bed. The smell of tobacco is evident. Left periorbital soft tissue
is markedly swollen and shrouding his underlying eyeball. Palpation of
the soft tissue is soft, nontender, and normal temperature. Separating
the swollen soft tissue with gentle up and down finger traction reveals
a normal conjunctiva with intact extraocular muscles and normal vision.
Pupil is normal size and reactive to light and accommodation.
A computed tomogpraphic scan of the face with intravenous contrast
was obtained as well as complete blood cell count and basic metabolic
panel. Computed tomogpraphic of the face reveals subcutaneous air
tracking from mediastinum, neck, and to the left eye. There is no evidence
of infection. Computed tomogpraphic of the chest with contrast reveals
pneumomediastinum without evidence of pneumothorax or
paraesophageal inflammation (Figs. 2–5).
The patient was admitted to the hospital for observation. Because of
a lack of signs or symptoms, no endoscopic gastroduodenoscopy or
bronchoscopy was performed. He was discharged the next day in stable
condition with decrease in periorbital emphysema and normal repeat
chest x-ray.
Although rare, it is important to rule out subcutaneous air tracking
from pneumomediastinum when evaluating unilateral periorbital swell-
ing. The differential diagnosis for periorbital subcutaneous emphysema
should include dental procedures [3], facial trauma, and sneezing [4].
The differential diagnosis for pneumomediastinum includes barotrauma,
pneumothorax, endoscopic retrograde cholangiopancreatography, and
esophageal perforation.
Idiopathic spontaneous pneumomediastinum is even rarer in an
asymptomatic patient with associated unilateral periorbital subcutane-
ous emphysema but can occur.
American Journal of Emergency Medicine 33 (2015) 1842.e1–1842.e2
Fig. 1. Left periorbital soft tissue swelling.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem

2. Jonathan Orton MD
Emily Collette FNP
Yadkin Valley Community Hospital, 624 W Main St
Yadkinville, NC, 27055
E-mail addresses: jonathan.orton@yadkinhospital.com (J. Orton)
emily.collette@yadkinhospital.com (E. Collette)
http://dx.doi.org/10.1016/j.ajem.2015.04.086
References
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emphysema: an unusual complication of endoscopic papillotomy. Gastrointest
Endosc 1988;34(6):473–5.
[2] Jaiswal Santosh Kumar, Sreevastava Deepak Kumar, Datta Rashmi, Lamba Navdeep
Singh. Unusual occurrence of massive subcutaneous emphysema during ERCP
under general anaesthesia. Indian J Anaesth 2013;57(6):615–7.
[3] Parkar Asif, Medhurst Claire, Irbash Mohammad, Philpott Carl. Periorbital oedema
and surgical emphysema, an unusual complication of a dental procedure: a case re-
port. Cases J 2009;2:8108.
[4] Gauguet Jean-Marc, Lindquist Patricia A, Shaffer Kitt. Orbital emphysema following
ocular trauma and sneezing. Radiol Case Rep 2008;3:124 [Online].
Fig. 2. Left-sided facial subcutaneous free air.
Fig. 3. Left-sided facial subcutaneous free air.
Fig. 4. Pneumomediastinum tracking into soft tissues of the neck.
Fig. 5. Pneumomediastinum.
1842.e2 J. Orton, E. Collette / American Journal of Emergency Medicine 33 (2015) 1842.e1–1842.e2