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M. Sakr
studies have reported diagnostic rates of up to
92% for US-guided FNA and approximately 98%
for US-guided CNB for supra-clavicular LNs
[378–380]. Selection of FNA or CNB depends on
operator experience, availability of cytologists/
pathologists, and imaging features of the lesion.
In the setting of a small target LN, necrotic
target, or when the target is adjacent to sensitive
structures, FNA may be preferred. However, it
does not provide the cellular architecture required
for accurate subtyping of lymphomas. When
next-generation genomic sequencing is required,
core biopsies of LNs have a high success rate of
providing adequate tissue [381]. US guidance
typically provides excellent visualization of both
the target and the biopsy device. The needle
should be visualized throughout its entire course.
Excision Biopsy
Supra-clavicular LN excision biopsy has
remained a diagnostic tool for intra-thoracic and/
or metastatic disease, even with the development
of more noninvasive procedures such as
US-guided biopsy and scalene biopsy during
mediastinoscopy [382].
An incision is made, often under local anesthesia, over the clavicle and laterally to the SCM
muscle. The clavicular part of this muscle can be
divided, and the whole muscle is retracted more
centrally to expose the area under the anterior
scalenus muscle. This area contains fat and multiple LNs, which can be easily and safely
removed. Additionally, with the use of this technique, the subclavian and jugular vessels can be
followed in the mediastinum to extract more LNs
and increase the possibility of diagnosis of intrathoracic lesions [383].
A lack of understanding the anatomy may
result in complications, which include (1) carotid
and subclavian artery bleeding, (2) thoracic duct
injury resulting in chylous stula, (3) phrenic or
RLN injury, (4) wound infection, and (5) tumor
seeding in cases of human papillomaviruspositive head and neck SCC [384, 385].
According to the latest guidelines set by the
American Academy of Otolaryngology-Head
and Neck Surgery (AAO-HNS), an open biopsy
is only necessary if FNAC, CNB, physical exam-
inations, and other ancillary test prove to be nondiagnostic [384].
10.6.5.5 Dierential Diagnosis
The differential diagnosis of supra-clavicular
lymphadenopathy generally categorizes as neoplastic, infectious, inammatory, and reactive
lesions. Ellison etal. (1999) performed a retrospective 5-year study in a large hospital on 309
supra-clavicular masses diagnosed with
FNA. Results showed that most of the masses
(55%) were malignant, with secondary
(metastatic spread) being far more frequent than
primary lymphomas (47% versus 8%, respectively) [378].
10.6.5.6 Prognosis
Prognosis of malignant infra-diaphragmatic
tumors after metastasis to Virchow’s node is generally extremely poor [386]. In case of abdominal
malignancy, identication of supra-clavicular
lymphadenopathy is considered as distant metastatic disease, which has a 5-year survival rate of
only 4%, and often precludes surgical resection
[365]. In case of intra-thoracic malignancy, lung
cancer has been reported to have the highest mortality of all cancers in the United States, and disease spread to the scalene LNs (N3) may
contraindicate surgical therapy [387]. In general,
prognosis may depend on the characteristics of
the primary tumor, and rapid diagnosis is important for providing appropriate treatment [388].
10.7 Cystic Swellings
ofthePosterior Triangle
10.7.1 Cystic Hygroma
10.7.1.1 Denition
A cystic hygroma is dened as “sequestration of
some lymphatics and loss of communication with
the main trunk” [389]. It can arise anywhere in
the body but is classically found in the posterior
triangle of the neck and axilla [390]. Cystic
hygroma is also known as “cystic lymphangioma” and “macrocystic lymphatic malformation”
[391].
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10 Lateral Cervical Swellings
247
10.7.1.2 Etiology
Embryologically, cystic hygromas originate from
sequestration of lymphatic tissue from lymphatic
sacs during the development of lymphaticovenous sacs [392]. It is because of this that they
commonly occur in the posterior triangle of the
neck [393]. These sequestered tissues fail to
communicate with the remainder of the lymphatic or venous system [394]. Later on, dilatation of the sequestered lymphatic tissues ensues,
resulting in the cystic morphology of these
lesions [395].
10.7.1.3 Epidemiology
Cystic hygromas are rare, accounting for approximately 6% of all benign lesions of infancy and
early childhood [396]. They are, however, the
most commonly presenting subtype of lymphangioma. Of all cystic hygromas, 75–90% is cervical, 20% axillary, and the remainder is seen in
other rare sites such as the inguinal region, retroperitoneal space, and mediastinum [397].
10.7.1.4 Clinical Picture
History-Taking
Currently, cystic hygromas are increasingly diagnosed by pre-natal US; a common sign is a neck
growth. More than 60% of cystic hygromas have
onset at birth and up to 90% become overt before
the age of 2years [398–402].
The usual presentation of cystic hygroma
apparent at birth is a large, diffuse, painless
mass with worries the parents. Its size varies
from few cm to a huge lump lling the whole
side of the neck, left more than right, causing
respiratory distress and feeding difculty due
to compression of major structures within the
neck, such as the larynx, trachea, or esophagus
[403]. The swelling is painless, non-tender,
and slowly growing, but occasionally, as a
result of infection, it increases rapidly in size,
becomes painful and exquisitely tender, with
erythematous overlying skin and the patient
may become febrile [389, 399, 400]. Rarely,
children with cystic hygromas display symptoms of newly onset obstructive sleep apnea
syndrome (OSAS) [404].
Physical Examination
Cystic hygroma appears soft/cystic, partially
compressible (but nor reducible), non-tender,
freely mobile, trans-illuminant, and non- pulsatile.
It is dull to percussion and uctuates easily.
Cystic hygroma develops in the SC tissues, thus,
it is supercial to the neck muscles and close to
the skin but are rarely xed to it. The overlying
skin can take on a bluish hue or may appear normal. A cyst in the posterior triangle may deeply
extend beneath the SCM muscle into the retropharyngeal space. It may be unilateral or bilateral. Local LNs should not be enlarged [397].
Cystic hygromas have been found to be associated with certain conditions, such as nuchal
lymphangioma, hydrops fetalis, and intra-uterine
death [405, 406]. Additionally, they can be associated with chromosome abnormalities in
25–70% of affected children such as Down syndrome, Turner syndrome, Klinefelter syndrome,
trisomy 18 and trisomy 13, though these are not
considered to be causative [407].
Complications that may be encountered with
cystic hygroma include difcult labor, infection
[408], bleeding [409], compression (respiratory
distress, dysphagia), sinus formation (due to
infection or trauma) [398–400], and deformity
(deformation of surrounding bony cranio-facial
structures or dentition, if left untreated).
10.7.1.5 Evaluation/Diagnosis
Antenatal Evaluation
On antenatal US, the characteristic appearance is
a multi-septate, thin-walled cystic mass that may
have a more complex echo texture with cystic
and solid components [410]. Detection of a cystic
malformation may prompt further investigation,
such as amniocentesis, to evaluate for genetic
abnormalities in the fetus, which may be found in
about 62% of cases [394].
Poste-natal Evaluation
Imaging Studies
Different imaging modalities such as MRI, CT
scan, and US are all helpful in delineating the
nature of a cystic neck mass [411]. Sonography
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M. Sakr
of the lesion usually demonstrates a multicystic
lesion with internal septations and no blood ow
on color Doppler US [395]. Usually, CT scan and
MRI can be employed to help in ascertaining the
extent of the lesion and its relation to nerves and
vessels and are particularly useful when surgical
management of the lesion is contemplated [395,
412]. Both, CT and MRI reveal a ring-like mar-
gin enhancement with sharp demarcation of cystic areas. The imaging study of choice is MRI.It
provides the best soft-tissue detail and can delineate the relation of the lesion to surrounding
structures. Contrast can be used to differentiate
hemangiomas from lymphangiomas. On MRI,
cystic hygromas appear hyper-intense on
T2-weighted images and hypo-intense on
T1-weighted images.
Pathology/Histological Findings
Histologically, cystic hygromas are characterized
by the proliferation of small lymphatic vessels
combined with brous tissue [413]. They exhibit
large macroscopic cystic spaces that are usually
multilocular, but may be unilocular in about 10%
of cases [397]. These spaces are lined by a singlelayer endothelium with a connective-tissue
stroma, and lled with clear- to straw-colored
uid, which is eosinophilic and protein-rich
[414]. Deep locules are quite large in size, but
they decrease in size toward the surface [403].
Individual cysts may be isolated or may freely
communicate. The surrounding stroma is brous
or fatty and may contain lymphoid aggregates,
smooth muscle, or other local tissues.
Cystic hygroma is a benign disorder; it grows
slowly, usually supercially, but may grow in any
plane of the neck. They may grow rapidly due to
the accumulation of lymph itself, blood secondary to hemorrhage, or pus secondary to infection
[415, 416].
10.7.1.6 Dierential Diagnosis
Congenital differentials include thyroglossal
cysts, branchial cleft cysts, dermoid cysts, or teratomas and other germ cell tumors. Other differentials include goiter and ranula in addition to
infective causes, such as reactive lymphadenopathies and neck abscess, or neoplastic causes, such
as lymphoma and soft-tissue tumors (rhabdomyosarcoma, lipoma, etc). The clinician should
also consider inammatory causes such as sarcoidosis, traumatic lesions such as hematomas,
and vascular causes such as carotid body tumors.
10.7.1.7 Treatment
The most preferred modality of treating cystic
hygroma remains complete surgical excision;
however, many recent reports have increasingly
documented remarkable results of treatment with
sclerosant agents [398–400, 408, 409, 416–418].
Other treatment modalities that have been
employed with variable results include simple
drainage, aspirations, radiation, laser excision,
radio-frequency ablation, and cauterization [416,
418, 419]. Treatment options will be individual-
ized depending on the size, anatomical location,
and complications of the lesion.
The indications of treatment are recurrent
bouts of infection in the lesion, respiratory distress, dysphagia, hemorrhage inside cystic
hygroma, sudden increase in the size of lesion,
lymph discharging sinus, and disgurement
[395]. The respiratory distress can be of severe
nature necessitating a tracheostomy due to complete or signicant laryngeal or tracheal compressions by external and sometimes laryngeal
lymphangiomas [400, 409, 416–418, 420–423].
10.7.1.8 Prognosis
In some series, the reported mortality has been as
high as 2–6%, usually secondary to pneumonia,
bronchiectasis, and airway compromise.
Obviously, this gure is pertinent in the larger
lesions. Prognosis (morbidity) of a patient with a
cystic hygroma largely depends on the anatomical site and whether or not the patient develops
any secondary complications. In general, morbidity is related to cosmetic disgurement and
impingement on critical cervical structures, such
as nerves, vessels, and laryngo-tracheal
complex.
Surgical excision of cystic hygroma generally
has good outcomes with complete resolution and
no recurrence provided the mass is completely
excised; however, in some cases, the surgical
excision complication rate can be as high as 53%
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10 Lateral Cervical Swellings
249
and recurrence rate up to 15–20% if residual tissue is left behind [392] This can be improved
through the use of adjuncts, such as sclerosing
agents. Cystic hygromas that are left without any
intervention are likely to continue to enlarge and
cause further complications. Unlike hemangiomas, cystic hygromas do not commonly resolve
spontaneously.
10.7.2 Pharyngeal Pouch (Zenker’s
Diverticulum)
10.7.2.1 Denition/Synonyms
Zenker’s diverticulum (ZD) is an acquired, posterior, pulsion, pharyngeal outpouching (diverticulum) that develops in the hypopharynx, typically
between the crico-pharyngeus (CP) muscle and
the inferior pharyngeal constrictor muscle [424].
It is a “false” diverticulum as it only involves the
mucosa and submucosal layers and does not
involve the muscular layer.
Synonyms include posterior pharyngeal pulsion diverticulum, pharyngo-esophageal pouch
or diverticulum, retro-pharyngeal pouch or diverticulum, posterior pharyngeal pouch or diverticulum, crico-pharyngeal achalasia, and
hypopharyngeal diverticulum.
resulting in herniation of the pharyngeal mucosa
through the weak part at the junction between the
inferior constrictor and CP muscle. The most
popular pathogenetic theories are structural
abnormalities of the CP muscle [430], increased
hypopharyngeal pressure, increased cricopharyngeal tone, and gastro-esophageal reux
[431]. It is suggested that a ZD involves impaired
CP muscle compliance, usually due to brotic
changes causing increase in the hypopharyngeal
pressure, leading to mucosal herniation at the
weak point just above the CP [430, 432]. The
resulting false diverticulum thus develops
between the transverse bers of the CP muscle
and the oblique bers of the inferior constrictor
muscle (Fig.10.27) [430, 432]; this area is often
known as “Killian triangle.”
10.7.2.4 Histopathology
Microscopic evaluation of the pouch usually
shows a sac lined with stratied squamous epithelium, and the submucosa lining often shows
brous tissue. No muscular layer exists (pseudodiverticulum). Rarely, ulcerations or evidence of
cancer, mainly SCC or carcinoma in situ, may be
present. Fibrosis surrounding the diverticulum is
common. Fibrous tissue limits the spread of
material that extravasates from the diverticulum
10.7.2.2 Epidemiology
Although ZD is a rare disorder in the general
population [425], yet it is the most common type
of pharyngo-esophageal diverticulum [426]. Its
incidence is estimated to be 1–2 per 100,000
patients/year and twice as common in males
[427]. It is primarily seen in elderly individuals,
peaking between the seventh and ninth decades
of life [428]. The rate varies in different parts of
the world being more common in Northern
Europe, USA, and Canada; it rarely occurs in
Japan and Indonesia and is extremely rare in
Africans and Asians [429].
10.7.2.3 Etiology/Pathophysiology
Zenker’s diverticulum is believed to be a “pulsion” diverticulum due to uncoordinated swallowing where the lower sphincter-like bers of
the inferior constrictor muscle do not relax,
t.me/Dr_Mouayyad_AlbtousH
Inferior
constrictor
muscle
icopharyngeus
muscle
Zenker’s
diver
Fig. 10.27 Anatomical site of Zenker’s diverticulum
bulging between the inferior constrictor and cricopharyngeus muscles
250
M. Sakr
during endoscopy thus reducing the likelihood of
local abscess formation.
10.7.2.5 Clinical Presentation
Symptoms
This false diverticulum retains food particles and
salivary secretions leading to regurgitation of
food (with no acid or bile taste in it), halitosis,
and dysphagia [433, 434]. Choking and bouts of
cough may be present, and if aspiration of food
particles occurs during night, a lung abscess may
develop. As the pouch increases in size, it hangs
down beside the esophagus causing dysphagia
and/or a neck swelling. Dysphagia, which occurs
in approximately 98% of patients, may be severe
enough and long-standing (for months or years)
to induce malnourishment and weight loss [434,
435].
Physical Examination oftheCervical
Swelling
The swelling appears behind the SCM muscle at
the junction of its upper and middle third, usually
to the left. It increases in size after eating and
straining and disappears on pressure with a gurgle (Boyce sign). Its shape is indistinct because
only part of its surface is palpable. The swelling
can be compressed and sometimes emptied but
not completely reduced. Its surface is smooth and
consistency is soft and sometimes indentable. It
is dull to percussion. It does not uctuate or
trans-illuminate. Cervical LNs should not be
enlarged.
A serious complication of ZD is aspiration
leading to pneumonia, bronchiectasis, or lung
abscess. Other complications include bleeding,
ulceration, tracheal compression, stula formation
with the trachea (diverticulo-tracheal stula), and
obstruction of the esophagus. Since this disease is
mainly a disease of the elderly, long-standing condition may lead to deterioration of pulmonary
function, in addition to cachexia, dehydration, and
malnutrition (from fear of eating). In these elderly
patients with ZD, the prognosis is typically poor,
and recurrence rate is high [436].
10.7.2.7 Investigations
Barium swallow with contrast video-uoroscopy
provide information regarding the size, location,
and characteristics of the mucosal lining of ZD,
and can achieve diagnosis of the condition
(Fig.10.28). Irregular or lling-defect within the
diverticulum may denote solid food remnants or
the presence of a carcinoma. Contrast videouoroscopy is able to see the pouch from different angles and provide constant monitoring of
swallowing, assessment of the function of pharyngeal muscles, and presence of absence of gastric reux [437].
10.7.2.6 Complications
Complications of ZD depend on the surgical
approach taken, patient age and co-morbidities.
Development of a SCC in the pouch is the most
dangerous complication. It occurs in 0.5% of
patients, with a male to female ratio of 5:1. It usually affects long-standing diverticula of more
than 7-year-duration. The patient as well as the
clinician should be alert whenever there is
increased dysphagia, weight loss, or blood in the
regurgitated food. Most patients will require total
pharyngo-laryngetomy (as for a post-cricoid carcinoma) [436].
t.me/Dr_Mouayyad_AlbtousH
Fig. 10.28 Barium swallow showing the pharyngeal
diverticulum (Zenker’s diverticulum) (red arrow)
10 Lateral Cervical Swellings
251
Esophagoscopy is essential for surgical evaluation. Staging of ZD is imperative to the overall
evaluation. Endoscopy may reveal brosis around
the diverticulum, which limits the risk of local
abscess formation. It may also show pooling of
food in the diverticulum.
10.7.2.8 Staging
There are three staging systems for ZD: Lahey,
Morton, and Van Overbeek staging systems. Only
one of the three may be used. Staging relies typically on the size of the pouch; the bigger the size,
the higher the staging [437]. Barium swallow
with video-uoroscopy is the radiographic methods used for staging.
Lahey classication includes the following:
– Stage I: Small mucosal protrusion is visible
– Stage II: A denite sac is seen but the esopha-
gus and hypopharynx are in line
– Stage II: The hypopharynx is seen in line with
the diverticulum, and the esophagus is pushed
anteriorly and appears indented.
10.7.2.9 Dierential Diagnosis
Although rare, cancers, such as SCC may be
present in conjunction with a ZD.This is imperative to rule out during an assessment. One must
ask about smoking history and consumption of
very hot or very cold liquids. Other differentials
include achalasia, gastro-esophageal reux disease (GERD) or Barrett’s esophagus, esophagitis,
stroke in the acute setting, and ulcerations due to
retention of food.
10.7.2.10 Treatment
Only symptomatic lesions need treatment; lesions
<2cm rarely require any intervention. In some
cases of ZD associated with achalasia,
“Botulinum toxin” may help relieve symptoms of
dysphagia. For all other large ZD, surgery is indicated; it is the mainstay treatment for symptomatic ZD [438, 439]. Patient selection is essential;
it is important to individualize optimal therapy
for each patient.
Treatment options include open (transcervical) and endoscopic (trans-oral) procedures.
Open procedures include (1) diverticulectomy
[440], (2) diverticulopexy [441], (3) diverticular
inversion (all three procedures are performed
with or without crico-pharyngeal myotomy), and
(4) crico-pharyngeal myotomy alone. Endoscopic
procedures include (1) endoscopic diathermy
application (Dohlman’s procedure), (2) endo-
scopic laser treatment, and (3) endoscopic
staple- assisted esophago-diverticulostomy. The
decision whether to perform the laser-assisted,
stapler- assisted, or open approach at the individual patient level can be inuenced by many factors, including age, co-morbidities [442], surgeon
experience [443], size of the pouch [444], and
patient anatomy.
Both open and endoscopic approaches can be
accomplished with many techniques, each of
which has its own advantages and disadvantages
[436]. Based on current evidence, traditional
“open surgery” is suitable for all kinds of diverticula, providing satisfactory long-term outcomes
and acceptable complication rates. However, it
needs general anesthesia and more invasive procedures. “Rigid endoscopic treatment” can be
done under general anesthesia and hyperextension of the neck. It might be technically difcult
where the diverticular septum cannot be well
exposed. “Flexible endoscopic therapy” can be
conducted without general anesthesia or neck
hyperextension; however, it is only suitable for
selected patients [445]. Each treatment option
has its pros and cons, but it is important to perform individualized therapy for each patient.
Minimally invasive endoscopic therapy should be
considered for debilitated patents with a middlesize diverticulum, and open surgery would be
preferred when difculty of diverticulum exposure is predicted [446–449].
10.7.3 Pneumatocele
10.7.3.1 Denition
Pulmonary pneumatoceles are thin-walled,
air- filled cysts that develop within the lung
parenchyma, usually in patients with emphysema and as a sequela to acute pneumonia,
commonly caused by Staphylococcus aureus
[441, 450, 451].
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M. Sakr
10.7.3.2 Epidemiology
The incidence of postinfectious pneumatocele
formation ranges from 2 to 8% of all cases of
pneumonia in children [452]. However, the frequency can reach 85% in patients with
Staphylococcal pneumonia. No specic racial or
gender predilection is observed. Pneumatoceles
are found more frequently in infants and young
children. Kunyoshi et al. (2006) reported that
70% of pneumatoceles occurred in children
younger than 3years [453].
10.7.3.3 Etiology
Infectious Causes
Infectious etiologies associated with pneumatocele formation include the following (1) bacterial
infections such as S. aureus (the most common),
Staphylococcal pneumoniae, Streptococcus
pneumoniae, Hemophilus inuenza, Eschercia
coli, group A Streptococci, Serratia marcescens,
Klebsiella pneumoniae, Pseudomonas aeruginosa, and Mycobacterium tuberculosis, and (2)
viral infections (adenovirus).
Noninfectious Causes
Noninfectious etiologies include hydrocarbon
ingestion, trauma, and positive pressure ventilation (especially among premature infants with
respiratory distress syndrome) [441, 450, 451].
Hyper-Immunoglobulin E (IgE) Syndrome
Although no particular genetic predisposition is
recognized, pneumatocele formation is associated with hyper-immunoglobulin E syndrome
(Buckley–Job syndrome) due to higher incidence
of S. pneumonia resulting from immunodeciency [454, 455].
10.7.3.4 Pathophysiology
The exact mechanism of pneumatocele formation
remains controversial. An endo-bronchial ballvalve mechanism leading to distal dilatation of
the bronchi and alveoli was proposed by Conway
(1951) [456] and Carrey (1953) [457]. However,
in 1972, Boisset concluded that pneumatoceles
are caused by bronchial inammation that ruptures the bronchiolar walls and causes the forma-
tion of “air corridors” [458]. Air dissects down
these corridors to the pleura and forms pneumatoceles, a form of sub-pleural emphysema [458].
Traumatic pneumatocele has a different pathophysiology from the infectious type [459], developing in a two-step process. Initially, the lung is
compressed by the external traumatic force,
followed by rapid decompression from increased
negative intra-thoracic pressure. A “bursting
lesion” of the lung occurs and leads to pneumatocele formation.
10.7.3.5 Clinical Presentation
History-Taking/Symptoms
Children present with typical features of pneumonia, including cough, fever, and respiratory
distress. No history ndings differentiate pneumonia with or without pneumatocele formation.
Physical Examination
Clinical examination may reveal variable degrees
(mild, moderate, or severe) of respiratory distress,
with tachypnea, retractions, grunting, and nasal
aring. High fever (40–41°C) is almost always
present. Auscultation of the chest reveals focal or
bilateral decreased breath sounds. Inspiratory
crackles are frequently audible [441, 450, 451].
As the pneumonia resolves and the pneumatocele persists, lung examination ndings can be
normal or reveals focal decreases in breath
sounds, depending on the size of the pneumatocele. In most children admitted to the hospital,
the average time from admission to the development of the pneumatocele is 4–7 days.
Occasionally, pneumatoceles are present on the
initial radiograph. A pneumatocele may appear as
a cystic swelling at the root of the neck; it
increases in size with straining and cough and
decreases with compression [441, 450, 451].
10.7.3.6 Complications
A tension pneumatocele can develop if airtrapping continues, most frequently with PPV
[460]. Expansion of the pneumatocele can cause
hemodynamic instability and severe airway
obstruction. If untreated, this can result in respiratory failure and death.
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253
Pneumothorax can occur from a pneumatocele rupturing into the pleural space causing lung
collapse or broncho-pleural stula.
Pyopneumothorax, hemo-thorax, hemopneumothorax, and pneumo-mediastinum have also been
contrast is not necessary to diagnose a pneumatocele but occasionally helps to differentiate it from
a lung abscess. Rarely, CT-guided needle aspiration of the pneumatocele can relieve compression
from a large and/or tension pneumatocele.
reported in the literature [461].
Secondary infection may occur, requiring
drainage to prevent the development of severe
lung abscess that may require surgical excision.
Drainage can be both diagnostic and therapeutic.
If drained, the uid should be cultured for bacteria and fungus [462].
10.7.3.7 Investigations
Procedures
Percutaneous catheter drainage is done in the
presence of a signicant tension pneumatocele,
or a secondarily infected pneumatocele, to
improve the patient’s cardiovascular status [463,
464].
Histological Features
Pathology is not commonly observed because
Laboratory Studies
If ndings are positive, blood culture can guide
antibiotic therapy. Sputum analysis is a good
noninvasive method to discover potential pathogens. Culturing pleural uid from thoracentesis
can also identify the causative organism. Tests for
bacterial antigen detection can be performed on
blood, urine, and pleural uid.
most pneumatoceles resolve without surgical
resection. However, a few reports documented
necrotic material around the pneumatocele.
Cavity walls can contain organized inammatory
cells with focal collections of multinucleated
giant cells. In 1972, Boisset reported the presence of “air corridors” between the bronchiolar
lumen and the interstitial space [361].
Imaging Studies
Pneumatoceles are usually evident on chest
radiographs by days 5–7 of hospitalization.
Rarely, it may be visible on the initial chest radiograph. Initial chest X-ray may reveal pneumonia,
pneumatocele (Fig.10.29), para-pneumonic effusion or empyema. Usually, chest CT scan with
Fig. 10.29 Plain X-ray chest showing pneumonia with
multiple pneumatoceles
10.7.3.8 Dierential Diagnosis
A pneumatocele should be differentiated from a
cystic or compressible mass in the lateral side of
the neck. Differentials also include bronchogenic
cyst, cystic adenomatoid malformation, pneumococcal infections, pneumonia, pulmonary seques-
tration, S. aureus infection, and Tuberculosis
(TB).
10.7.3.9 Treatment
Accurate and early diagnosis is the key to a successful treatment of patients with pneumatocele.
Treatment of the underlying pneumonia with
antibiotics is the rst-line therapy. Close observation in the early stages of the infection and periodic follow-up care until resolution of the
pneumatocele is usually adequate treatment
[465]. In most circumstances, pneumatoceles are
asymptomatic and do not require surgical intervention. Conservative treatment includes the use
of high-frequency oscillation ventilation (HFOV),
decreasing the mean airway pressure, positioning
affected side down, and unilateral ventilation of
unaffected lung [441, 466–468].
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M. Sakr
Percutaneous needle decompression is considered when the pneumatocele has the following
characteristics: (1) occupying greater than 50%
of the hemi-thorax [29], (2) creating signicant
atelectasis, (3) broncho-pleural stulae development, (4) tension pneumatocele [469], (5) persistent signs of chest infection or infection within
the cyst, and (6) the risk of inability to follow-up
the patient in the outpatient clinic. Kogutt etal.
(1999) reported that percutaneous needle decompression of a pneumatocele may carry the risk of
the development of broncho-pleural stula [470].
Percutaneous catheter drainage of a pneumatocele that involves more than 50% of the hemithorax with severe atelectasis, tension
pneumatocele, broncho-pleural stula, or
infected pneumatocele is rarely needed. The
pneumatocele can also be successfully managed
by the injection of brin sealant via a pigtail catheter [464]. Recently, Muniraman et al. (2021)
reported that bedside US-guided chest tube drainage was successfully used to decompress a large
pneumatocele in an unstable preterm infant
[471].
Surgical resection is almost never required for
the management of pneumatoceles. The indications for video-assisted thoracoscopic surgery or
open surgery include (1) prolonged, persistent air
leak, (2) hemo-thorax or pneumo-thorax due to
pneumatocele rupture, (3) failure of lung expansion, (4) progressive enlargement of the pneumatocele, and (5) compression of functional
parenchyma. Video-assisted thoracoscopy has
recently been used successfully to treat enlarging
multicystic cases [467].
10.7.3.10 Prognosis
In general, a noncomplicated pneumatocele carries an excellent prognosis. The natural course is
slow, but complete resolution with no further
clinical sequelae usually occurs within 3months
to 2years. However, rare complications, including tension pneumatocele, can lead to death from
respiratory or cardiovascular collapse due to progressive enlargement of the pneumatocele. Thus,
if complications happen, early surgical intervention would be benecial to avoid mortality/morbidity [472].
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