Penetrating aortic ulcer: a rare cause of neck swelling

A woman in her late 80s presented at midnight to the emergency department with sudden onset difficulty breathing, neck pain and neck swelling. There was no history of recent illness. Paramedics recorded saturations of 80% on air, improving to 96% with 15 L of oxygen via a non-rebreathe mask. CT angiogram of the aorta demonstrated a penetrating ulcer of the anterior aortic arch with associated mediastinal and deep neck space haematoma. The patient was intubated and underwent emergency thoracic endovascular aortic repair to arrest bleeding. A ruptured penetrating aortic ulcer is a rare cause of mediastinal haematoma causing neck swelling and life-threatening airway compromise. This case highlights an important, although rare, differential diagnosis for sudden onset neck swelling and difficulty breathing.