Radiology Quiz Case 2

Radiology Quiz Case 2 Marc Cohen, MD; Marilene B. Wang, MD; Chau T. Nguyen, MD; University of California, Los Angeles, UCLA Medical Center (Drs Cohen and Wang), and Ventura County Medical Center, Ventura, Calif (Dr Nguyen)

A

27-YEAR-OLD HISPANIC MAN PRESENTED to the emergency department with acute bilateral neck swelling that had occurred after a severe bout of coughing. His medical history was significant for long-term use of methamphetamine, marijuana, and tobacco. Two weeks before admission, he had noted a new-onset, nonproductive cough. On the morning of admission, he had a rather forceful episode of coughing that was subsequently accompanied by bilateral neck swelling, described as “small balloons under the skin.” He denied change in voice, dyspnea, sore throat, odynophagia, dysphagia, hemoptysis, palpitations, and chest pain. Computed tomography of the chest and neck revealed pneumomediastinum with air tracking into the supraclavicular, axillary, and posterior triangle areas bilaterally (Figure 1 and Figure 2). A soft tissue mass measuring 10⫻8 mm in transverse diameter was also seen in the area of the right subglottis (Figure 3). The findings of esophagoscopy were normal. The anterior tracheal wall had a grayish pseudomembranous appearance on direct laryngoscopy and bronchoscopy. The larynx appeared unremarkable. No specific area of mucosal injury was noted. The subglottic swelling appeared as a polypoid, fungating, very friable mass, just inferior to the right vocal cord. A biopsy was performed, and pathologic analysis of the specimen revealed a marked, submucosal, predominantly chronic inflammatory cell infiltrate con-

sisting of numerous histiocytes, many plasma cells in small clusters, lymphocytes, and a few neutrophils. The results of acid-fast bacilli and Gomori methenamine silver staining were negative. Cultures were positive for Klebsiella rhinoscleromatis. What is your diagnosis?

Figure 1.

Figure 3.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, JUNE 2007 615

Figure 2.

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