Telephone diagnosis of a strange voice.

A previously healthy 25-year-old man made a telephone call to our institute 3 h after surfacing from a self-contained underwater breathing apparatus (scuba) dive. Earlier that day, he had been spear-fishing using compressed air to a maximal depth of 9 m for approximately 2 h. Immediately after surfacing from the dive, he had noticed a significant change in his voice, and complained of dyspnea with pleuritic chest pain. Over the telephone, his voice sounded distorted with an unusual nasal quality, and a probable diagnosis was made. He was then asked to come to the emergency department. Physical examination revealed subcutaneous emphysema at the anterior triangle of the neck. Auscultation of the lungs and heart was normal, and the neurologic examination was unremarkable. A chest radiograph (Fig 1), a lateral cervical radiograph (Fig 2), and an anteroposterior cervical radiograph (Fig 3) were obtained.