Clinical Image A 49 year old female presented to the emergency department complaining of dyspnea with chest tightness .The symptoms began after her husband put the nozzle of high-pressure air compressor into her mouth with violent behavior 2 hours ago (Figure 1). Onexam, the vital sign was normal despite of respiratory rate 24 breaths per minute, with oxygen saturation of 97% on room air. Face swelling and oral laceration were noted (Figure 2).

Massive subcutaneous emphysema and crepitus over chest and neck area were observed. The chest X-ray showed massive bilateral pneumothorax, penumomediastinum with subcutaneous emphysema over chest wall and neck (Figure 3). The CT confirmed the diagnosis of pneumoperitonium and left pneumo-retroperitoneum (Figure 4). The bronchoscopy revealed no evidence of tracheal bronchial tree injury (Figure 5) and panendoscopy revealed any esophagus injury (Figure 6). The 28-Fr chest tubes were inserted into both sides. She was discharged nine days following admission without consequences