Neck Crepitus: Causes, Diagnosis, and Management
Neck crepitus is a crackling or grating sensation felt in the neck that can indicate air in the soft tissues (subcutaneous emphysema), joint abnormalities, or potentially serious aerodigestive tract injuries. Understanding the underlying cause is essential for proper management and preventing potentially life-threatening complications.
Types and Causes of Neck Crepitus
1. Subcutaneous Emphysema
- Definition: Air trapped in the soft tissues of the neck
- Causes:
- Pneumomediastinum (air in the mediastinum)
- Penetrating neck injuries
- Upper aerodigestive tract injuries
- Forceful activities (vomiting, coughing, strenuous exercise)
- Post-surgical complications
2. Articular Crepitus
- Definition: Joint-related grinding or popping
- Causes:
- Arthritis of cervical spine joints
- Temporomandibular joint (TMJ) disorders
- Scapulothoracic crepitus (between shoulder blade and chest wall) 1
3. Traumatic Crepitus
- Definition: Crepitus resulting from trauma
- Causes:
- Fractures
- Penetrating neck injuries
- Strangulation (absence of normal laryngeal crepitus) 2
Clinical Evaluation
Key History Elements
- Onset (sudden vs. gradual)
- Associated symptoms (pain, dysphagia, hoarseness, dyspnea)
- Recent trauma or procedures
- Recent strenuous activities
- History of respiratory conditions (asthma)
Physical Examination
- Palpation for subcutaneous air (feels like "Rice Krispies" under the skin)
- Assessment of laryngeal crepitus (side-to-side movement of larynx)
- Evaluation for neck swelling, bruising, or tenderness
- Complete head and neck examination including oral cavity
- Neurological assessment
Diagnostic Approach
Imaging
Based on clinical presentation and suspected etiology:
Radiographs:
- First-line imaging for suspected subcutaneous emphysema
- Can detect air in soft tissues, pneumomediastinum 3
CT Scan:
- Most sensitive for detecting soft tissue gas and determining extent
- Can delineate compartmental location of air
- Essential for suspected aerodigestive tract injuries 3
MRI:
- Limited role in acute setting with suspected air
- More useful for evaluating chronic neck pain or radiculopathy 3
Management Based on Etiology
1. Subcutaneous Emphysema with Pneumomediastinum
- Usually self-limited and benign in healthy individuals
- Conservative management:
2. Suspected Aerodigestive Tract Injury
- High index of suspicion with history of trauma
- Immediate evaluation for:
- Airway compromise
- Associated facial/neck injuries
- Management options:
- Direct laryngoscopy and esophagoscopy for suspected injuries
- Broad-spectrum antibiotics
- Surgical exploration for large lacerations or airway compromise 6
3. Articular Crepitus (Joint-Related)
- Conservative treatment:
- Postural and strengthening exercises
- Local modalities
- Pain management
- Surgical options for refractory cases:
- Partial scapulectomy (for scapulothoracic crepitus)
- Bursectomy 1
Red Flags Requiring Urgent Attention
- Rapidly expanding neck swelling
- Progressive respiratory distress
- Stridor or voice changes
- Dysphagia or odynophagia
- Hemoptysis
- Neck pain with fever
- History of penetrating trauma
- Crepitus after recent neck surgery
Special Considerations
Necrotizing Fasciitis
Crepitus may be a sign of necrotizing fasciitis, a life-threatening infection:
- Characterized by gas in deep fascial planes
- Requires immediate surgical debridement
- Broad-spectrum antibiotics 3
Strangulation
- Absence of normal laryngeal crepitus may indicate laryngeal trauma from strangulation
- Important forensic finding even when external signs are minimal 2
Conclusion
Neck crepitus warrants thorough evaluation to determine its cause. While many cases represent benign conditions that resolve with conservative management, some indicate serious underlying pathology requiring urgent intervention. CT imaging is the most sensitive diagnostic tool for detecting and characterizing soft tissue gas in the neck 3.