General Hospital of Vienna, Vienna, Austria
Correspondence to: Istepan Kurkciyan, MD, Universitätsklinik für Notfallmedizin, Allgemeines Krankenhaus der Stadt Wien, Währinger Gürtel 18-20/6D, 1090 Wien, Austria; e-mail: Istepan.Kuerkciyan@AKH-Wien.ac.at
We read with interest the article by López-Peláez et al (June 2001).1 This reminded us of a 28-year-old man of Chilean origin who was under detention due to an immigration offense. He was admitted to our emergency department with a painfully swollen face and neck. The physical examination revealed subcutaneous emphysema in the face, neck, and supraclavicular region with normal cardiorespiratory function. Chest radiography and CT of the mediastinum showed a pneumomediastinum with a small bilateral pneumothorax. An esophageal radiogram with contrast did not detect any leakage.
The etiology of the condition could not be explained by these diagnostic procedures, and the symptoms disappeared without active treatment within an observation period of 3 days in the patient ward of the detention facility. However, during the following weeks, the subcutaneous emphysema reappeared two times. Again, no active treatment was considered necessary. In the absence of any other possible cause, a self-induced injury was suspected. Further interviews with the patient indeed resulted in the admission that after self-induced punctures in the oral cavity with a sharp object, he had repeatedly performed a Valsalva maneuver. In addition, he explained that this procedure was common knowledge in South American prisoners, and was used frequently to at least achieve better living conditions by bringing about a transfer from a prison to a medical facility and possibly a better opportunity of escaping from detention.
That this technique is not only national South American “know how” but is common also in Europe is documented by several similar reports in the German-language literature that have been published at least as early as 1969.2–4 Sluga and Grünberger5 reported such self-induced injuries by prisoners in general.
In summary, differential diagnosis of recurring swelling of face and neck including subcutaneous emphysema and pneumomediastinum should also include self-induced oral injury followed by Valsalva maneuver, especially in patients under detention.
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