Dysphagia
https://doi.org/10.1007/s00455-020-10143-w
CLINICAL CONUNDRUM
An Unusual Case of Odynophagia
Chanticha Laohakittikul1 · Patorn Piromchai1 
Received: 2 May 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Clinical Conundrum
In January 2019, an 18-year-old male with no significant
medical history presented at the emergency department with
sudden odynophagia and sore throat after cheerleading train-
ing. He had been a member of the university’s cheerleading
team since his freshman year, participating in weekly prac-
tice sessions, which required him to sing and sometimes
shout.
He reported no shortness of breath, voice changes, dys-
phagia, or chest pain. He had no recent history of upper
respiratory infection, foreign body ingestion, dental proce-
dures, or trauma. His vital signs at presentation were nor-
mal (temperature: 36.5 °C; heart rate: 82 beats per minute;
blood pressure: 141/75 mmHg; respiratory rate: 20 breaths
per minute; pulse oximetry: 100% on room air). Results
of physical examination of the head and neck region were
unremarkable, with no bulging or redness of the posterior
pharynx and no neck crepitus on palpation.
Flexible fiberoptic laryngoscopy revealed no bulging of
the posterior pharyngeal wall, no pooling saliva, and nor-
mal vocal fold movement. Radiological evaluation was per-
formed. Lateral radiography of the neck revealed a linear air
column in the retropharyngeal space (Fig. 1).
What is the Diagnosis?
From lateral radiography of the neck, the patient was diag-
nosed with retropharyngeal emphysema. Retropharyngeal
emphysema is characterized by the presence of free air
in the retropharyngeal space. Most cases of retropharyn-
geal emphysema are caused by trauma, iatrogenic injury,
obstructive respiratory disease, or dental extraction.
* Patorn Piromchai
patorn@gmail.com
1 ing, is rare. The most common symptoms of this condition
Department of Otorhinolaryngology, Faculty of Medicine,
Khon Kaen University, Khon Kaen 40002, Thailand
Retropharyngeal emphysema that occurs after instant posi-
tive pressure in the upper airway, such as through forced
swallowing, physical exertion, coughing, or shouting, is rare.
The patient was advised to rest his voice and was pre-
scribed a 7-day course of oral amoxicillin–clavulanic acid
and analgesic mouth spray. He was given an appointment
for a follow-up visit in 1 week. According to a telephone
interview, the patient’s sore throat and odynophagia had
improved by the next day and was completely resolved
within 1 week. We followed the patient for 9 months, during
which there was no recurrence of neck pain or odynophagia.
Discussion
Most cases of retropharyngeal emphysema are caused by
dental extraction, trauma, iatrogenic injury, infection, or
obstructive respiratory disease. In 1944, Macklin and Mack-
lin [1] concluded that increased intrapulmonary pressure
from parturition, violent straining, or violent cough could
cause alveolar disruption and pulmonary interstitial emphy-
sema. The air leak can extend upward into the space of the
neck, face, and axilla.
Shine et al. [2] reported a case of a singer who presented
with acute retropharyngeal and cervical emphysema with
pneumomediastinum that occurred while singing at an
engagement party. Joseph et al. [3] reported four patients
with spontaneous pneumomediastinum presenting with ret-
ropharyngeal emphysema, two of whom had a history of
instant positive pressure in the upper airway. One had a vig-
orous cough and presented with odynophagia and neck pain,
and the other complained of odynophagia and chest pain
after forceful exertion to dislodge a car from a snowbank.
After conservative treatment, the symptoms completely
resolved and rarely recurred.
Retropharyngeal emphysema that occurs after instant
positive pressure in the upper airway, such as through
forced swallowing, physical exertion, coughing, or shout-
are sore throat, dysphagia, and odynophagia without signs
13
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Fig. 1  Film soft tissue of the neck, lateral view showing the air col-
umn in the retropharynx
of respiratory distress or dysphonia. The typical patient is
young and male. In the case presented above, physical find-
ings were unremarkable. Fiberoptic laryngoscopy revealed
no bulging of the posterior oropharyngeal wall, patent supra-
glottic and glottic airway, and normal vocal fold movement.
Radiographic neck examination revealed free air in the ret-
ropharyngeal space, which confirmed the diagnosis [3].
Treatment for retropharyngeal emphysema typically con-
sists of outpatient rest, instructions to avoid strenuous activi-
ties, and the administration of analgesics [4]. The symptom
usually resolves within 7 days with no recurrence. The con-
dition has a very benign course and does not require hospi-
talization [2, 3].
To our knowledge, this is the first case report of
retropharyngeal emphysema presented with sudden
13
Laohakittikul and Piromchai: An Unusual Case of Odynophagia
odynophagia that occurred in a young male teenager after
cheerleading practice. A thorough airway evaluation, includ-
ing history, physical examination, fiberoptic laryngoscopy,
and radiographic imaging of neck should be performed care-
fully. Therapy is typically conservation consisting of vocal
rest, specific instructions, and analgesics.
Funding  This study has no financial support or funding.
Compliance with Ethical Standards 
Conflict of interest  We declare no conflict of interest for this study.
Ethical Approval  The research protocol was reviewed and approved
by the Khon Kaen University Ethics Committee for Human Research
(HE631109). This article does not contain any studies with human
participants performed by any of the authors.
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
References
1. Macklin MT, Macklin CC. Malignant interstitial emphysema of
the lungs and mediastinum as an important occult complication
in many respiratory diseases and other Conditions: an interpreta-
tion of the clinical literature in the light of laboratory experiment.
Medicine. 1944;23(4):281.
2. Shine NP, Lacy P, Conlon B, McShane D. Spontaneous ret-
ropharyngeal and cervical emphysema: a rare singer’s injury. Ear
Nose Throat J. 2005;84(11):726–7.
3. Smith JL, Hsu JM. Spontaneous pneumomediastinum pre-
senting with retropharyngeal emphysema. Am J Otolaryngol.
2004;25(4):290–4.
4. Granich MS, Klotz RE, Lofgren RH, Partlow RC, DiGregorio LI.
Spontaneous retropharyngeal and cervical subcutaneous emphy-
sema in adults. Arch Otolaryngol. 1983;109(10):701–4.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Chanticha Laohakittikul  MD, FRCOT
Patorn Piromchai  MD, MSc, PhD, FRCOT, FICS