to the neck and is worse with deep inspiration and position changes, subcutaneous crepitus, Hamman sign (crunching heart sounds), dysphagia, and dysphonia This diagnosis must be distinguished from pneumothorax, pericarditis, and esophageal perforation Pleural effusions can cause chest pain associated with decreased breath sounds and dullness to percussion on physical examination Pleurodynia, often secondary to coxsackievirus B infection, causes sharp chest pain, fever, and a friction rub Aspiration of a foreign body into the trachea or esophagus may occur without such history in a toddler or even in an older child, and approximately 50% of these children may complain of chest pain Foreign bodies lodged in the airway often present with chest pain, cough, decreased breath sounds, and unilateral wheezing However, auscultatory findings may be unimpressive despite a positive history Although pulmonary embolisms (see Chapter 99 Pulmonary Emergencies ) are rare in children, they can present with pleuritic chest pain, cough, hypoxia, hemoptysis, dyspnea, respiratory distress, and the sense of impending doom Usually this condition is associated with risk factors such as obesity, oral contraceptive use, pregnancy, collagen vascular disease, nephrotic syndrome, cigarette smoking, recent surgery, immobility, trauma (particularly spinal injury), a positive family history, a hypercoagulable condition (known or unknown), or prior cardiorespiratory problems Finally, children with sickle cell disease can develop a vasoocclusive crises resulting in acute chest syndrome GI diseases account for approximately 4% to 7% of pediatric patients with chest pain Diseases include gastroesophageal reflux, esophagitis, gastritis, ulcer disease, and rarely esophageal rupture or spasm History is important with regard to the relationship of the symptoms to meals and body position Pain of gastroesophageal reflux is typically described as burning, worse in the recumbent position, related to eating, and improved with antacid or hydrogen ion blocker therapy The physical examination is usually normal or positive for epigastric tenderness Foreign bodies in the GI tract can cause chest pain, drooling, dysphagia, and odynophagia The history often uncovers this diagnosis and radiography may be helpful Spontaneous esophageal perforation (Boerhaave syndrome) is secondary to transmitted increased pressure against a closed glottis most often seen with vomiting but also straining, coughing, defecation, seizure, childbirth, or forceful nose blowing Presentation includes symptoms of chest pain, crepitus, pneumomediastinum, and hematemesis to hemorrhage and shock Mackler triad includes vomiting, chest pain, and subcutaneous emphysema There are case reports of adolescents diagnosed with diffuse esophageal spasm via