Ticking Time Bomb: Case of a Motor Tic Leading to Pneumomediastinum

Abstract Introduction: Spontaneous pneumomediastinum is a rare clinical phenomenon often seen in young, tall, underweight men, triggered by activities that increase intrathoracic pressure, such as vigorous exertion or vocal strain. This condition involves alveolar rupture and subsequent dissection of peribronchial and perivascular sheaths, allowing air to spread into the mediastinal space. Similarly, rare cases of pneumoparotid and pneumoparotitis occur from increased intraoral pressure causing air to enter the parotid gland via an incompetent Stensen's duct. Although spontaneous pneumomediastinum and pneumoparotid are distinct, both can present in atypical demographics and are often associated with psychological or habitual factors, like motor tics or self-induced behaviors. Case Report: A 21-year-old woman with a past medical history significant for anxiety, motor tic characterized by sudden gasps of air, history of parotitis, and BMI of 26.5 presented to the emergency department with sudden onset of bilateral neck pain after standing abruptly during a sporting event. She subsequently developed hoarseness, dysphagia, and dysphonia. The patient denied any preceding injuries, intrinsic lung disease, recent procedures, tobacco use, or recreational drug use. The patient was noted to be hemodynamically stable on room air in no distress. Physical exam showed diffuse tenderness over the anterior neck without signs of trauma, crepitus, or mediastinal crunch on auscultation of the cardiac apex. While a one-view chest X-ray was non-diagnostic, a soft-tissue neck X-ray revealed gas extending from the neck base through the retropharyngeal space. A CT scan of the chest confirmed the presence of symmetric pneumomediastinum while ruling out underlying esophageal and pulmonary pathologies. Upon diagnosis, the patient was observed overnight and treated with continuous oxygen, non-opiate analgesia, and empiric antibiotics. The patient was discharged in stable condition with instructions for activity and vocal limitations. At her one-month hospital follow-up with her primary care physician, she reported full symptom resolution, with no cervicalgia or dysphagia. Discussion: This case highlights spontaneous pneumomediastinum in a patient who does not fit the typical profile of young, underweight men. Her presentation mirrors some aspects observed in pneumoparotitis cases, where episodes are often linked to psychiatric or habitual factors, like motor tics. In the reviewed literature, many pneumoparotitis cases were associated with anxiety or self-induced behaviors that increase intrathoracic pressure, suggesting that psychological and habitual components may also play roles in spontaneous pneumomediastinum presentation outside typical demographic groups. Conservative management, with observation and analgesia, has proven effective, as shown in pneumoparotitis and pneumomediastinum.