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The heart and thoracicaorta 125
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Persistent ductus arteriosus
Pathology
If the channel between the aorta and pulmonary
artery fails to close at the time of birth, blood will be
shunted from the systemic circulation with its higher
pressure into the pulmonary circulation, resulting in
pulmonary hypertension (Figure13.3). In time, pulmonary vascular resistance increases and exceeds
peripheral resistance, at which time the shunt
reverses, deoxygenated blood from the pulmonary
artery passes into the systemic circulation and the
patient becomes cyanosed. It carries a risk of development of infective endocarditis and eventually right
ventricular failure.
Clinical features
In neonates with a large duct, shunting may progress
rapidly and cardiac failure may occur in infancy. A
duct with moderate flow tends to present later with
exertional dyspnoea. Most commonly, the patient is
asymptomatic and the condition is diagnosed on
finding the characteristic machinerymurmur, with systolic accentuation best heard over
like continuous
the second left space anteriorly. In infants, the bruit
may be purely systolic.
Special investigations
• Echocardiography and angiography will demonstrate a persistent ductus, and indeed, the cardiac
catheter can often be manipulated through the
ductus into the aorta.
Treatment
Operative ligation and division of a persistent ductus
should be undertaken on diagnosis, and before irreversible pulmonary hypertension or cardiac failure
has occurred. Percutaneous endovascular insertion
of an occlusive device into the ductus may achieve a
cure without surgery.
Coarctation ofthe aorta
Pathology
This is a congenital narrowing of the aorta, which, in
the majority of cases, occurs in the descending aorta
just distal to the origin of the left subclavian artery
Left recurrent
laryngeal nerve
Aorta
(a) (b)
Figure13.3 (a) A persistent ductus arteriosus– note its close relationship to the left recurrent laryngeal nerve.
(b) Coarctation of the aorta. Reproduced from Ellis H, Mahadevan V (2019) Clinical Anatomy, 14th edn. Oxford:
Wiley- Blackwell.
Persistent ductus arteriosus
Left vagus
nerve
Pulmonary
artery
Brachiocephalic trunk
Left carotid artery
Left subclavian
artery
Coarctation of the aorta
126 The heart and thoracicaorta
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close to the obliterated ductus arteriosus. The pathogenesis of coarctation formation may be related to
the presence of abnormal ductus tissue. Coarctation
can rarely occur in other sites up and down the
aorta. The stenosis is usually extreme, with only a
pinpoint lumen remaining. There is sometimes a coexistent cardiac anomaly, most commonly a bicuspid aortic valve.
Blood reaches the distal aorta via collateral connections between branches of the subclavian, scapular and intercostal arteries, and by the anastomosis
between the internal thoracic and inferior epigastric
arteries. Although the blood supply to the lower part
of the body is diminished, patients with coarctation
seldom have peripheral gangrene, although occasionally they complain of intermittent claudication.
The danger of coarctation is due to the effects of
hypertension proximal to the coarctation. This is
often severe and is likely to result in cerebral haemorrhage or left ventricular failure. The mechanism of the
hypertension is probably due to the relatively poor
blood supply to the kidneys, which results in release
of renin and renal hypertension.
Clinical features
The diagnosis is considered in any child or young
adult with hypertension. In addition to hypertension,
the most characteristic physical sign, is absent,
diminished or delayed femoral pulsations in relation
to the radial pulse, and the condition is confirmed by
a large difference in the blood pressure between the
arm and leg. A systolic murmur is sometimes present
posterior in the left chest, and large collateral blood
vessels may be seen or felt in the subcutaneous tissues of the chest wall.
Special investigations
• Chest X- ray in an adult may show an enlarged
heart, and often the ribs are notched by the large
intercostal collateral blood vessels bypassing the
stenotic area.
• Echocardiography in an infant is important to
exclude co- existing cardiac anomalies.
• Angiography and CT will confirm the diagnosis.
end- to- end anastomosis of the proximal and distal
aorta or, if the gap to bridge is too great, an arterial
graft interposed between the two aortic ends. Balloon
angioplasty is an alternative treatment.
Thoracic aortic aneurysms
Aneurysms can occur in any place in the body
(Chapter12), but the aorta is particularly liable to be
affected. Aneurysms of the arch of the aorta were
once commonly syphilitic, but now are mainly due to
atherosclerosis and sometimes connective tissue diseases, e.g. Marfan syndrome
descending thoracic aorta are usually atherosclerotic.
Once they have reached a sufficient threshold size,
surgery is indicated to reduce the risk of rupture.
A thoracoabdominal aneurysm is an aneurysm
extending across the diaphragm and involving the
origins of the coeliac, superior mesenteric and renal
arteries.
3
. Aneurysms of the
Clinical features
Aneurysms of the ascending aorta may be asymptomatic and discovered incidentally or present with
chest pain, or breathlessness due to aortic valve
disease.
Aneurysms of the arch of the aorta may compress
the trachea or ulcerate into it; they are liable to stretch
the left recurrent laryngeal nerve, leading to hoarseness, and may obstruct the left lower lobe bronchus,
producing an area of collapse.
Aneurysms of the descending thoracic aorta may
produce pain in the back or erosion of vertebrae or
may press on the oesophagus, producing dysphagia,
and even rupture into it. Not surprisingly, this is the
most lethal cause of haematemesis.
Special investigations
• Chest X- ray may show the extent of the aneurysm
due to calcification in its walls.
• CT and magnetic resonance (MR) imaging are use-
ful in demonstrating the size and extent of the
Treatment
This is desirable before complications arise and consists of excision of the stenotic segment and either
3
Antonine Marfan (1858–1942), Professor of Paediatrics,
Hôpital des Enfants Malades, Paris, France. Marfan
syndrome is due to a mutation in the brillin- 1 gene on
chromosome 15, and manifests with cardiovascular, skeletal
and ocular abnormalities.
aneurysm and its relation to the major vessels of
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the neck.
Echocardiography is important to diagnose asso-
•
ciated aortic valve disease and assess heart
function.
The heart and thoracicaorta 127
False
lumen
Treatment
Aneurysms of the ascending aorta and arch require
cardiopulmonary bypass for adequate surgical treatment, which consists of partial excision of the aneurysm and insertion of a prosthetic graft with
appropriate junction limbs to the main aortic
branches. Whole- body cooling and deep hypothermic circulatory arrest (DHCA) is sometimes required
to treat arch aneurysms.
Aneurysms of the descending thoracic aorta
require a left heart bypass for their surgical treatment,
which is similar in principle to those of the arch. More
recently, endovascular stenting of descending thoracic aneurysms has proved to be a promising
alternative.
Complications
• Bleeding and the other complications of cardiac
surgery in general (see above).
Stroke due to atherosclerotic embolism or malper-
•
fusion during surgery.
•
Spinal ischaemia is due to loss of flow in the great
radicular artery (of Adamkiewicz
from the aorta near T10 and supplies the lower
part of the spinal cord. This results in paraplegia.
4
), which arises
Aortic dissection
Intimal
tear
Type A Type B
Figure13.4 Stanford classication of aortic dissection.
tamponade, or into the thoracic or abdominal cavity
with fatal haemorrhage.
Aetiology
Cystic medial degeneration weakens the wall of the
aorta and enables the splitting to occur. It is usually
found in atherosclerotic, hypertensive patients or
those with connective tissue disease, e.g. Marfan or
Danlos syndrome.
Ehlers-
Pathology
An aortic dissection consists of a tear in the wall of the
aorta, usually in the thoracic component, which
allows blood to dissect along a plane of cleavage in
the media and extend proximally and distally. The
false passage thus formed may rupture internally into
the true lumen, decompressing itself and resulting in
an aorta with a double lumen. Such a patient may survive. More commonly, the dissected aorta ruptures
externally into the pericardium, producing cardiac
4
Albert Adamkiewicz (1850–1921), Professor of Pathology,
Cracow, Poland.
Classication
Aortic dissection has been classified into type A and
type B (Stanford classification
•
Type A dissection affects the ascending aorta and
occurs in two- thirds of cases.
• Type B dissection specifically excludes the ascending aorta but may involve the arch and/or
descending aorta. It occurs in one- third of cases.
5
Stanford University School of Medicine, Stanford, CA,
USA. e Stanford classication was described in 1970
by Norman Shumway (1923–- 2006) and colleagues in the
Division of Cardiovascular Surgery. Shumway has been
described as the father of heart transplantation.
5
, Figure13.4)
128 The heart and thoracicaorta
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Clinical features
The patient usually presents with a sudden, severe
pain in the chest, which may radiate to the arms, neck
or abdomen, or with a tearing interscapular pain. In
addition, there may be signs of shock, either from cardiac tamponade or from external rupture of the aneurysm. Patients with aortic dissection are sometimes
initially diagnosed as suffering from a myocardial
infarction, and an ECG may not help differentiate
between the two conditions because if the coronary
ostia are involved, coronary occlusion may have
occurred. In type A dissections, the aortic valve may
become incompetent as the root dilates.
As the dissection in the wall of the aorta progresses,
the origins of the main arterial branches may become
occluded, producing progression of symptoms and
the disappearance and reappearance of peripheral
pulses. If the renal vessels are involved, there may be
haematuria or anuria. One or both femoral pulses
may disappear with leg ischaemia. Mesenteric
ischaemia is usually diagnosed late and carries a
poor prognosis.
Neurological abnormalities may also occur, ranging from hemiparesis, as a result of occlusion of the
carotid and subclavian artery origins, to paraesthesia,
as a result of peripheral nerve ischaemia.
Special investigations
• Chest X- ray shows widening of the mediastinum in
two-
thirds of patients and a small left pleural
effusion.
Contrast- enhanced CT shows the diagnostic flap
•
across the aortic lumen with true and false lumens,
and is the key investigation to determine the classification and extent of disease.
•
Echocardiography may also demonstrate a flap in
the proximal aorta, a pericardial collection and
aortic regurgitation.
Treatment
Once the diagnosis is made, treatment depends
largely upon the type of dissection:
Type A dissections should be managed surgically as
an emergency because of the risk of fatal mechanical
complications. It is said that the risk of death is 1% per
hour. The surgery aims to replace the ascending aorta
with a prosthetic tube graft. The original tear should be
excised if possible, and the aortic valve repaired or
replaced if involved. Deep hypothermic circulatory
arrest may be required to perform the distal anastomosis in the arch. The mortality risk is between 10% and
20%, but often nearer 100% without intervention.
Type B dissections are usually treated without surgery
initially, and hypotensive drugs are used, reducing systolic pressure to 100–120 mmHg to prevent further
extension of the dissection. The false lumen may then
thrombose. Any complicating organ, limb or mesenteric ischaemia resulting from the dissection may
require revascularization. An aneurysm resulting from
a chronic dissection may require treatment if it enlarges
or produces pressure symptoms. Treatment of the
descending thoracic aorta is often delivered by vascular
surgeons rather than cardiac surgeons in the UK,
although some cases will require both specialist teams
to provide their expertise. In cases where there is evidence of impending aortic rupture or nona visceral artery, endovascular placement of a covered
stent (thoracic endovascular aortic repair [TEVAR]) is
appropriate. The stent is placed to cover the proximal
entry into the false lumen and to rethrough the collapsed true lumen.
perfusion of
establish blood flow
The chest andlungs
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Aman Singh Coonar
Learning objectives
✓ To have knowledge of the types of chest injury and their management
✓ To have knowledge of pneumothorax and thoracic empyema, which are
common conditions
✓ To know the steps of chest drain insertion
✓ To have knowledge of lung cancer and its management; this is
particularly important as it is a common cause of cancer death in the UK
14
Thoracic surgery has undergone a revolution such
that the majority of procedures are now conducted as
video-
assisted thoracic surgery (VATS). In the UK,
lobectomy with lymph node dissection is performed
more commonly as VATS than by open thoracotomy.
A thoracoscopic approach is used from the simplest
thoracoscopic inspection of the chest and pleural
biopsies to complex anatomical resection. Pathways
of care rely on a multidisciplinary team (MDT)
approach with an emphasis on early mobilization
and enhanced recovery.
Injury tothe chest
Ventilation of the lungs depends on patent main airways and pulmonary alveoli, rigid bony skeleton of
the thorax, and integrity of the nerves and muscles
that control the movements of the ribs and diaphragm. Traumatic disruption of the chest wall can
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
be lethal unless treatment is instituted rapidly.
Dangerous complications of chest injury include:
• paradoxical breathing;
• pneumothorax;
•
lung contusion;
• penetration of the lung (pulmonary laceration);
• haemothorax;
• cardiac contusion;
• cardiac tamponade due to laceration of the heart;
•
large- vessel damage.
Serious harm can also result from blunt (crush)
injuries that do not penetrate the chest; thus, the
trachea or a main bronchus or the aorta may be
ruptured, lung contused or torn, and papillary
muscles of the heart or the coronary arteries may
be damaged.
A common injury pattern is that seen in surviving
occupants of a road traffic accident when the patient
has been restrained by the seat belt and airbags.
Characteristically, there is bruising in the seat belt
pattern. Often, there are associated facial and neck
injuries. There may be a mid- sternal fracture as well
as broken ribs. There may be some lung and myocardial contusions. There may be a pneumothorax and
haemothorax. In higher energy deceleration impact,
there may be death due to transection of the aorta or
airway rupture.
130 The chest andlungs
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Sternal fracture
Clinical features
A common site is mid- sternum. Usually, there is little
displacement. There may be a retrosternal haematoma. Almost all such injuries will unite and heal
without longadmitted for a period of cardiac monitoring as rhythm
disturbances may occur.
Fractures ofthe ribs
Clinical features
A common injury to the chest is fracture of the ribs by a
direct blow. The commonest pattern is that of fractures
of the seventh, eighth and ninth ribs, in which the break
usually occurs in the region of the
patient complains of pain in the chest overlying
thefracture, and this pain is intensified by springing the
ribs with gentle but sharp pressure on the sternum.
Special investigations
• Chest X- ray may confirm rib fractures and lung
damage or haemorrhage that might not have been
term problems. The patient is usually
mid- axillary line. The
suspected from the patient’s symptoms. A chest
ray may not always demonstrate a fracture; if the
Xpatient has clinical signs of fractured ribs, they
should be treated for this condition in spite of a
negative Xshow fracture callus and confirm the diagnosis.
•
Computed tomography (CT) scan is essential for
assessing patients with complex chest injuries and
penetrating injuries, and will demonstrate fractures and underlying visceral injury. Patients may
go directly to CT as part of the trauma management protocol.
Echocardiography can demonstrate a pericardial
•
collection and cardiac tamponade.
•
Thoracic ultrasound can also demonstrate pleural
collections.
ray. A repeat X- ray at 2 weeks may
Complications
Flail chest
Crush injuries of the chest, in which the whole sternum is loosened by fractured ribs on either side or
adjacent ribs are fractured in two places, result in the
condition of flail chest (Figure14.1). On inspiration,
the flail part of the chest wall becomes indrawn by the
negative intrathoracic pressure, as it is no longer in
structural continuity with the bony/cartilaginous
Air shunted
from one lung
to the other
on inspiration
Figure14.1 Flail chest. On inspiration, the detached segment of the chest wall is sucked inwards, producing
paradoxical movement. The mechanics of breathing are impaired.
Air movement
within the lungs
Inspiration
Flail
segment
sucked in
Expiration
The chest andlungs 131
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thoracic cage. Similarly, in expiration, the flail part of
the chest is pushed out while the rest of the bony cage
becomes contracted. This is termed paradoxical
movement. With progressive ventilatory failure the
patient becomes hypoxic due to failure of adequate
expansion of the affected side. Hypercapnia can also
occur as the patient tires.
Pneumothorax
If a bony spicule penetrates the lung, air escapes into
the pleural cavity and will result in a pneumothorax.
A tension pneumothorax (Figure14.2) results if the
tear in the visceral pleural is valvular, allowing air to be
sucked into the pleural cavity at each inspiration but
preventing air returning to the bronchi on expiration.
A tension pneumothorax produces rapidly increasing
dyspnoea; the trachea and apex beat are displaced
away from the side of the pneumothorax, and on the
left side, cardiac dullness may be absent. The chest on
the affected side gives a hypernote, and there can even be bulging of the intercostal
spaces.
This is an emergency, and decompression of the
pleural space is needed by the careful insertion of a
cannula or small incision.
resonant percussion
Subcutaneous emphysema
(surgical emphysema)
When a fractured rib tears the overlying soft tissue
and allows air from the pneumothorax to enter the
subcutaneous tissues, subcutaneous emphysema
results. The skin over the trunk, neck and sometimes
face gives a particular crackling feel to the examining
fingers (crepitation), and in severe cases, the face and
neck may become grossly swollen. The alternative
name, ‘surgical emphysema’, is misleading as it is
rarely caused by surgeons. Although distressing, subcutaneous emphysema almost never causes any lasting harm. Incisions in the skin may allow the air to
escape more rapidly.
Sucking wound ofthe chest
A pneumothorax will also result from a penetrating
wound of the chest wall produced, for example, by a
knife stab or gunshot wound. The lips of the wound
may also have a valvular effect so that air is sucked
into the cavity at each inspiration but cannot escape
on expiration, thus resulting in another variety of tension pneumothorax, which has been vividly named a
‘sucking’ wound of the chest.
Trachea
deviated
away
Hyper-resonant
percussion
note over
pneumothorax;
no breath sounds
Air sucked
into the pleural
cavity on
inspiration
Apex beat displaced medially
Figure14.2 Tension pneumothorax
produced by a valvular tear in the lung.
Air is sucked into the pleural cavity
on inspiration and cannot escape on
expiration.
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Haemothorax
A haemothorax often accompanies a chest injury and
may be associated with a pneumothorax (haemo-
pneumothorax). The bleeding is usually from an
intercostal artery in the lacerated chest wall or from
underlying contused lung, but on occasions may
result from injury to the heart or a great vessel.
Traumatic asphyxia
Lung expansion. This should be achieved by
•
insertion of an intercostal chest drain with underwater drainage.
Stop bleeding. Small haemothoraces, which do not
•
interfere with the expansion of the lung, require
only observation, but a large haemothorax should
be drained, again with underwater seal as for a
pneumothorax (Figure14.3). Continued bleeding
is an indication for an exploratory thoracotomy or
thoracoscopy.
With severe crush injuries of the chest, the sudden
sharp rise in venous pressure produces extensive
bruising and petechial haemorrhages over the head,
neck and trunk. There are often subconjunctival
haemorrhages and nasal bleeding. Any area of the
skin that has been subject to compression at the time
of injury (e.g. from a tight collar, braces or spectacles)
is protected, and these areas remain mapped out on
the body as strips of normal skin, giving a characteristic appearance to the patient.
Other visceral injury
It is important to remember that penetrating wounds
of the chest may also injure the underlying diaphragm
and thence the abdominal viscera. Thus, it is common for a knife or bullet wound of the left chest to
penetrate the spleen or, on the right side, to damage
the liver– incorrect placement of a chest drain may do
the same!
Treatment
The priorities in the management of chest injuries are
as follows.
•
Airway control. This may involve the passage of
an endotracheal tube, particularly where head
injury co- exists with chest trauma. Aspiration of
vomit is prevented by sucking out the oropharynx
and passing a nasogastric tube to empty the
stomach.
Breathing. Ensure the patient is breathing and
•
maintaining adequate oxygenation. A saturation
monitor should be employed, and intubation and
ventilation considered in the presence of hypoxaemia or hypercapnia.
• Sucking wounds. These should be closed. In an
emergency, a dressing pad should be applied over
the hole and secured in place.
Simple rib fracture
• Pain relief may be achieved by paracetamol,
non- steroidal anti- inflammatory drugs (NSAIDs),
opiates or nerve modulating drugs (such as
pregabalin or gabapentin). Local and regional
blocks with local anaesthetic can also be used and
are very effective.
•
Vigorous physiotherapy and mobilization is
administered to encourage deep breathing. The
patient should be encouraged to be out of bed and
walking as much as possible.
• Strapping of the chest wall should be avoided as it
inhibits thoracic movement and encourages pulmonary collapse.
Flail chest
• Support the flail segment in the emergency situation by means of a firm pad held by short- term
local strapping. This stops the paradoxical movement and air shunting.
• Good pain control, with paravertebral or
even epidural anaesthetic blocks, normovolae-
mia and antibiotics are keys to successful
management.
• Rib fixation, for which there are now a range of
specialist devices, has an increasing role, particularly where there is displacement.
• High- flow oxygen or non- invasive ventilation with
facemask or nasal continuous positive airway
pressure (CPAP).
•
Endotracheal intubation and positive pressure ven-
tilation will stop the paradoxical movement, as the
chest wall now moves as a single functional unit.
The treatment is continued for a few days until
stability of the chest wall occurs. This is only performed if other measures are ineffective or
intubation is needed for other reasons.
Underwater seal
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below the level
of the chest
The chest andlungs 133
Underwater
seal
prevents
air being
sucked in
Figure14.3 Underwater seal
chest drain in the treatment of a
pneumothorax. Air escapes from the
pleural cavity on expiration but cannot
be sucked back through the water seal
on inspiration (as shown here). The
water bottle is placed below the level of
the chest to ensure uid does not reux
into the thoracic cavity.
Pneumothorax
A traumatic pneumothorax requires insertion of a
chest drain, in contrast to a spontaneous pneumothorax, which may resolve without intervention.
Tension pneumothorax
Emergency treatment is required by decompressing
the chest with a cannula and then subsequently
inserting an intercostal chest drain.
A chest drain is inserted into the pleural cavity via
an intercostal space, the fifth space being preferred in
between the mid- axillary and anterior axillary line.
This should be clear of the heart and hilum. The overlying skin is cut, and then the remaining insertion is
done by blunt dissection into the pleural cavity. It is
very important that a fingertip is inserted to check
that the lung has moved away. At this point, the drain
is inserted. The insertion should be gentle. A pair of
forceps, surgical clip or tracheal dilator can be used to
guide the drain into the pleural cavity; this is usually
done without the trocar within the drain. The drain is
then secured, and the hole tightly closed. The drain is
then connected to an underwater seal. When the
pressure in the pleural space is increased on expiration, the air escapes through the water but cannot
enter the chest at inspiration, as this is prevented by
the water seal. This essential safety valve has been an
important step in the development of safe thoracic
surgery (Figure14.3).
expansion of the lung is assisted by attaching
Re-
the drain to low-
A bronchopleural fistula, due to rupture of a bronchus into the pleural space, should be suspected if the
pneumothorax persists, or if the lung remains collapsed despite suction on the drain bottle, and there
is a large ‘air leak’. It may require a minimally invasive
VATS or thoracotomy to inspect and/or repair.
pressure suction.
Penetrating wounds ofthe chest
Immediate application of a dressing is required in
order to prevent suction of air into the pleural space.
If the patient is unstable, emergency thoracotomy
may be needed. In stable patients, significant
penetrating wounds should be investigated with a CT
scan. Minor cases require only wound toilet with an
underwater intercostal chest drain to allow escape of
any accumulated blood or air in the pleural space.
134 The chest andlungs
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Wounds require exploration if there is continuous
blood loss, suspicion of diaphragm damage or concern about injury to other organs. Remember that
abdominal organs, the neck and spine can be injured
from a chest wound.
Cardiac tamponade
This is suspected in any penetrating injury but particularly anteriorly between the midIt is characterized by a rise in venous pressure and a
fall in arterial pressure. The heart sounds are distant,
and the cardiac shadow enlarged on chest X-
Urgent echocardiography is a definitive investigation, either identifying the problem or excluding
tamponade as a cause of shock and diverting attention elsewhere; CT scan can also provide similar
anatomical information. If present, treatment is
emergency surgical exploration; the pericardium is
opened, the blood is evacuated and the cardiac laceration sutured.
clavicular lines.
ray.
Lung abscess
Aetiology
• Central airway obstruction, such as a foreign body
or slowly growing obstructive tumour; it is rarely
seen with other malignant tumours because of the
rapid progress of the disease.
• Inhalation pneumonitis, for example, inhaled
vomit or pus.
Inhaled foreign body, for example, at dental
•
extraction.
Infected cyst.
•
• Infected pulmonary infarct.
Clinical features
The history may suggest the primary cause. There is
usually fever and other features of acute sepsis,
although the disease may sometimes run a more
chronic course. If the abscess ruptures into the
bronchus, there is a foul productive cough and bad
breath.
Complications
• Empyema (pus in the pleural cavity).
• Metastatic cerebral (a feared complication of all
pulmonary sepsis) or embolic abscesses
elsewhere.
Special investigations
• Chest X- ray shows a solid opacity or a fluid level if
the abscess communicates with the bronchus.
Bronchoscopy may demonstrate the primary cause
•
if this is a foreign body or tumour.
CT scan will accurately locate the abscess and
•
confirm the diagnosis. Percutaneous CT-
drainage may be possible and effective.
guided
Treatment
The underlying cause may itself require treatment.
The mainstay of therapy for lung abscess is antibiotics and chest physiotherapy. Sometimes percutaneous or bronchoscopic drainage is required. An
obstructed airway should be opened if possible.
Surgical excision is required only for the small percentage that fail to respond to this therapy, when
some underlying cause needs to be treated or when,
in a late case, there is a complicating empyema that
requires drainage.
Empyema
An empyema (pyothorax) is a collection of pus in the
pleural cavity.
Aetiology
• Underlying lung disease, such as pneumonia.
A parapneumonic fluid collection becomes
secondarily infected from the underlying lung.
• Bronchiectasis or carcinoma of the lung; tuberculous empyema is now uncommon.
• Penetrating wounds of the chest wall or infection
following a transthoracic operation.
• Perforation or rupture of the oesophagus.
• Transdiaphragmatic infection from a subphrenic
abscess.
Complications
• Progression to a thick- walled empyema cavity,
which will not respond to simple drainage.
• Discharge through the chest wall (empyema
necessitans).
• Cerebral abscess or abscess elsewhere from
haematogenous spread.
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