Introduction 13 3 4 12 Case report Case 1 A 13-year-old girl presented with increasing complaints of an unusual crackling sensation and sound in her neck during three days. At that time, she complained of neck pain and headache. When these complaints started, she had a sore throat with painful swallowing. Further medical history mentioned a Cooper test, a test of physical fitness, at school two weeks earlier. There had been no trauma or injury and no coughing or vomiting. 2 1 Fig. 1 Coronal computed tomography (CT) reconstruction with mediastinal emphysema and subcutaneous emphysema in both axillas and lower neck regions in patient 1 with anorexia nervosa (AN)  Within a week, the subcutaneous emphysema disappeared. She was referred to an eating disorders clinic to manage her eating disorder. She never showed any signs of purging during treatment and recovered from her AN. Case 2 A 17-year-old girl with known AN and vomiting presented with extreme malnutrition requiring refeeding. She complained of unusual crackling sensation in her neck during eight days, starting after a choking incident while drinking, followed by coughing. The same day, she felt pressure on her chest. During the following days, her neck became swollen and her voice became hoarse. The swelling had already subsided considerably at the time of presentation. 2 2 Fig. 2 arrow  Laryngopharyngoscopy did not reveal mucosal lesions. The laryngeal mucosa was slightly swollen. After refeeding, she was referred to an eating disorders clinic to manage her eating disorder. Within two weeks, the subcutaneous emphysema further resolved spontaneously. Discussion 8 13 1 9 8 8 8 6 Spontaneous pneumomediastinum is rarely associated with AN. Only 21 publications related to this association are reported by Pubmed. 1 2 4 5 7 8 8 We speculate that the state of malnutrition contributes to the risk of spontaneous pneumomediastinum. 10 11 10 10 14 With thinner alveolar walls and the loss of alveoli, malnourished individuals are at risk of alveolar wall rupture. Since known factors of increased intra-alveolar pressure were absent in our first case and since clinical examination and radiographic study did not reveal an esophageal or upper airway perforation, we must assume that subclinical alveolar leaks with subsequent air dissection, pneumomediastinum and diffuse soft tissue emphysema occurred because of weakness of the alveolar wall and thinning of the connective tissue caused by severe malnutrition. Therefore, even with a minimal increase of intra-alveolar pressure, such as that which may occur during usual daily activities, such as a choking incident, can become the cause of air leaks, as in our second case.