19yr gentleman presents with throat and chest pain at a friend’s party, the night before had snorted cocaine ~0200 noticed pain in throat and pain with swallowing over the next few hours.

He developed pain across his anterior chest wall – pleuretic – constant during the next day noticed -voice change; sounds deeper - neck feels swollen and gets a 'crackling noise' when he touches it or swallows subcutaneous emphysema present in neck bilaterally, extending to apex of neck (Figure 1).

Figure 1: CXR of pneumomediastinum and subcutaneous emphysema