Subcutaneous emphysema (SE) is air infiltration in the skin’s subcutaneous layer. The development of SE indicates that air is occupying a deeper body region [7]. Air preferentially accumulates in the subcutaneous region with minor tension until the pressure increases enough to travel along another plane, leading to extensive spread [8]. The level of surgical emphysema can vary from mild subcutaneous emphysema to severe life-threatening airway compression, pneumomediastinum, and pneumothorax complications [9]. Subcutaneous emphysema and pneumomediastinum are infrequent post-operative presentations ofsleeve gastrectomy; this was especially notable in our patient sincesheunderwent uneventful post-operative recovery and was discharged and followed up two weeks after surgery. Nevertheless, her recent events of excessive forceful vomiting and retching led to the development of SE.

Aberrant air in the mediastinum and subcutaneous regions can originate from the oesophagus, lungs, airways, neck, and abdominal cavity [10] when (SE) and pneumomediastinum form spontaneously. The two most likelycauses are alveolar rupture or oesophageal rupture called Boerhaave’s syndrome (BS) [11]. The mechanism of alveolar rupture in vomiting appears to be abdominal contraction against a closed glottis, resulting in increased intra-alveolar pressure. On the other hand, oesophageal ruptures occur due to excessive vomiting and retching, leading to increased intra-luminal pressure of the oesophagus, subsequently exceeding the wall’s tensile strength [12]. Both conditions are associated with symptoms such as retrosternal chest pain, cough, sore throat, dysphonia, dysphagia, palpitation, neck discomfort, and dyspnoea [13]. However, BS patients present with a classic triad of vomiting, chest pain, and subcutaneous emphysema (Mackler’s triad) and are generally septic due to mediastinitis.

The diagnosis of (SE) and pneumomediastinum can be difficult due to its delayed presentation and vague symptoms. After a careful medical history and detailed physical examination, it is vital to exclude other diseases with a similar presentation, such as ischemic heart attack, pulmonary embolism, pericarditis, musculoskeletal disorders, and chest infections. The X-ray of the chest is a helpful tool to diagnose this condition. Reliable signs on posterior chest X-rays include the separation of the mediastinal pleura from the left heart border and subcutaneous emphysema [14]. X-rays are also abnormal in 90% of cases of BS with additional signs, including left pleural effusion and hydropneumothorax [15]. Water-soluble swallow and diluted barium studies help to exclude perforation of the oesophagus; however, a false-negative result occurs in 26–66% of all patients [16]. Computer tomography (CT) scans with oral contrast are helpful when the diagnosis is questionable, as well as a diagnosis of perforation in the oesophagus.

The management of SE involves the determination of the underlying cause, analgesia, rest, and reassurance. Furthermore, patients may require antibiotics as a prophylaxis to prevent mediastinitis. Subcutaneous emphysema is typically a self-limiting condition once the diagnosis is confirmed [17]. Most presentations last a few days, including a hospital stay, as in our case report. Nevertheless, some authors suggest that hospitalization is not always required. Possible complications are tension pneumothorax, tension pneumomediastinum, air embolism, and pneumopericardium, although these are all rare [13].