A man, 26 years of age, presented to a hospital emergency department complaining of a sudden onset of a sore throat 6 hours previously while consuming a carbonated drink at work. The pain commenced about lunchtime, after he had been mixing concrete powder, and since then had been intermittent and was becoming more severe. He subsequently complained of upper chest pain that radiated down his left arm and into his jaw. He denied any nausea, vomiting or shortness of breath but had severe pain on swallowing. He had no relevant past medical history, was not taking
any medications and had no allergies.
Observations were unremarkable with temperature 36.6ºC, pulse 54 bpm and regular, pulse oximetry 99% on room air, and respirations 16 breaths/min with equal air entry on both sides. His oropharynx showed no tonsillar enlargement and only slight erythema. On palpation he had tenderness in the anterior part of his neck, but no tenderness in the supraclavicular region. There was no subcutaneous emphysema. A routine electrocardiogram showed normal sinus rhythm and no acute ischaemic changes and bloods were taken for a troponin level, which was normal. While recognising that the likely diagnosis was pharyngitis, the emergency nurse practitioner was concerned that his symptoms were more severe than expected for such minor clinical findings. For this reason, a soft tissue X-ray of his neck was taken (Figure 1).
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