Topic: SURGERY Chest wall, Pleura, Mediastinum

Lecturer: Dr. Ayson (lecture + batch 2018 trans)

Date: November 25, 2016
Transcribed by: Salvalosa, et. al.
10. What condition that is also known as a trapped lung?
Fibrothorax
OUTLINE
1. INJURIES TO THE CHEST WALL
a. Fractures
b. Chest wall contusion
c. Traumatic Asphyxia
d. Blast Lung Injury
2. INJURIES TO THE PLEURA
a. Pleural Effusions
b. Pneumothorax
c. Tension Pneumothorax
d. Empyema
e. Hemothorax
3. CHEST WALL TUMORS
a. Benign Primary Chest Tumors
b. Malignant Primary Chest Tumors
4. CHYLOTHORAX
5. TUMORS OF THE PLEURA
a. Malignant Mesothelioma
b. Fibrous Tumors of the Pleura
6. MEDIASTINUM

*CASE
An 18 y/o male was brought to the ER in CV distress with
multiple stab wounds on his right chest about 2 hours post
injury. Pale looking, bloody shirt, neck vein not distended.
With 2 stab wounds, the first one is about 1.5 cm right
th
posterior chest at the 5 ICS around 4 cm from the spine. The
nd
th
2 stab wound is about 1.5 cm anterior chest wall at the 8
ICS anterior axillary line. Vital signs (ER): BP: 80/50, PR:
120bpm, RR: 5
How will you manage this case? ABCs (primary survey
ATLS)
*Discussion is mostly focused on pneumothorax
CHEST WALL
Provide protection to vital structures (heart, lungs, and
great vessels)
Provide airtight structure capable of maintaining
negative inspiratory pressure generated by the
diaphragm in ventilating the lungs.

*Pretest
1. What is the initial management of a patient with
chest wall trauma?
ABC (primary survey)
2. What is the initial management of a patient with
sucking chest wound?
3 sided occlusion dressing
3. What condition is managed by simple figure of 8
splinting?
Clavicular fracture
4. Condition that gives butterfly sign on chest film.
Blast lung injury
5. What is the most common benign tumor of the
chest?
Chondroma
6. What chest wall tumor that gives a ground-glass
appearance?
Fibrous Dysplasia
7. The mainstay treatment for sarcomas.
Surgery
8. What type of asbestos fiber that is identified to
cause malignant mesothelioma?
Crocidolite
9. What is the primary cause of spontaneous
pneumothorax?
Subpleural bleb rupture

*picture is not exactly from the ppt

rd
th
CXR showing fractured 3 to 8 left posterior rib

*picture is not exactly from the ppt

CXR showing pneumothorax of the right lung red line
marking the border of the atelectatic lung; green line showing
1

SURGERY Chest wall, Pleura, Mediastinum

radiolucency which signifies air in the thoracic cavity. There is

no shift of the mediastinal structure.
INJURIES TO THE CHEST WALL
Incidence and Etiology
Chest wall trauma 2nd to head injury as leading cause of
trauma death in USA.
2 million cases/year
10% in US
Overall 25% - trauma mortality
25% contributing factor
30% requires hospitalization
25% with associated injuries.
15% - will not require operation Fractures

Fractures
Increased likelihood associated injuries
1st, 2nd rib and scapular fracture
Elderly low reserves. Can already be suffering from
COPD, heart problems or asthma, injury to chest wall
can be fatal.
Pediatrics high reserves, pliable rib cage, needs
expeditious work-up
o The patient does not need to have a fracture for you
to be worried for the patient. Patient may have
pneumothorax in the absence of fracture

Treatment:
Pain Management
Pulmonary toilet
o Aggressive and regular suctioning of secretions.
o Incentive spirometry to inflate the lungs to the
fullest.
o Chest physiotherapy
o 50% may progress to pneumonia
o 25% develop pleural effusion
Positive pressure ventilation
Bronchoscopy with thoracentesis and appropriate
antibiotics (Gram negative)

Initial Management
In ANY trauma, always do your ABC! Regardless of the
site of the trauma! (primary survey)
Pulmonary contusion fluid restriction
o Within 24-48 hours after an injury, rule out
pulmonary contusion first.
P.E. By palpation, youll be able to feel crepitations
which are very painful and are indicative of rib fracture.
o Bruits, murmurs great vessels or cardiac injury

Long Term Sequelae

Chronic pain
Chest wall deformity
Dyspnea on exertion (due to decreased lung volume)

Diagnostics
CXR to identify if you have pneumothorax or
hemothorax, or mainly parenchymal disorders.
Chest Bucky To visualize osseous structures for
fractures, etc. (more of bony parts)
CT scan more sensitive and specific (seldom requested
in trauma patients, except if px is rich)
ABG Respiratory difficulty
ECG blunt cardiac contusion
Initially: Review of Chest PE (Master Bates okay?)
o Inspection
o Palpation
o Percussion
o Auscultation

Use a 3 sided occlusion dressing This will allow air to

come out but prevent air from coming in. (In hospital
setting (ER), use vaselinized gauze; in field, you can use
clean plastic)
If occluded, this may further cause tension
pneumothorax
Most dramatic injury
Flail Chest Multiple rib fractures with segmental
fractures (per rib)
o The ribs are actually floating in such fractures.
>2 consecutive, segmental rib fracture
o Results to paradoxic chest wall motion.
o Delayed presentation (9 days)
o >50% with pulmonary contusion.

Simple Rib Fracture

50% are missed by routine X-ray
Point tenderness & pain on respiration are diagnostic.
Atelectasis & pneumonia
Tx: pain management & pulmonary toilet

Sternal Fracture
5% patient with blunt chest trauma
Body or manubrium
X-ray, CT scan, ECG
40% with rib fracture
Tx: Pain Control, ORIF

Specific Injuries
Sucking chest wound can lead to tension
pneumothorax and patient can die in minutes if not
treated immediately.

Clavicular Fracture
Common among pediatric patients
rd
75% middle 3
Tx: simple figure of 8 splint, pain management, ORIF
(figure of 8 or X is at the back)
Scapular Fracture
Not a common injury
High energy trauma
75% other significant injury

SURGERY Chest wall, Pleura, Mediastinum

Tx: non-operative, ORIF (glenoid acromion clavicular)

Sternoclavicular dislocation
Uncommon, high force injury
2/3 associated with other chest injury
Anterior > posterior
Pain with shoulder movement and palpable bony
prominence.
Anterior dislocation
o Conscious sedation
o Closed reduction
Posterior dislocation
o CT scan
o ORIF
o Compression of vessels and other structures in the
thoracic cavity

Pleural Effusions
Commonly seen in patients with:
CHF
Pneumonia
Carcinoma
Pulmonary Embolism
Viral disease
Coronary Artery bypass surgery
Cirrhosis with ascites

Chest wall contusion

Deep soft tissue
Breast hematoma
o Cold compress first to close damaged vessels and
prevent hematoma. After 24 hours, warm compress
to reabsorb the hematoma.
Wound care and pain management

Costophrenic angle is obliterated once there is at least

200-300 ml of fluid accumulation the size of 1
intercostal space!!
Normally, between 5 and 10 L of fluid enters the pleural
space each day by filtration through microvessels
supplying the parietal pleura (located mainly in the less
dependent regions of the cavity.

Transudate
Protein poor ultrafiltrates of plasma
Clear
Straw colored
Exudate
Protein rich pleural fluid
Inflammation
Tumor invasion
o Turbid, bloody, purulent

Traumatic Asphyxia
Significant compression and crush injury to chest
Associated with intra-abdominal injuries
Upper extremities, torso and facial cyanosis, edema,
and petechial hemorrhages
Secondary to SVC compression
Cerebral edema (due to SVC compression, there is
congestion of venous flow to the brain)

Transudative Pleural Effusion

Blast Lung Injury

Major immediate cause of death Compressive wave
results in alveolar rupture and capillary disruption with
resultant hemorrhage and edema
100% with ruptured tympanic membranes
50% with burn injuries
Butterfly sign on chest film progressive infiltrate
from pulmonary hilum spreading out distally in a
butterfly pattern.
Tx: supportive with mechanical ventilation and
pulmonary toilet.

INJURIES TO THE PLEURA

PLEURA
Parietal pleura:
Mesothelial lining

Visceral Pleura:
No somatic innervations

CHF
Cirrhosis
NS
SVC obstruction
PD
GN
Exudative Pleural Effusion
Neoplastic diseases
o Metastatic
o Mesothelioma
Infectious diseases
o Bacterial infections
o TB
o Fungal infections
Pulmonary embolization
Gastrointestinal Diseases
o Pancreatic diseases
o Subphrenic abscess
o Post abdominal surgery
OB-gyne Diseases
o Ovarian hyperstimulation
o Endometriosis
o Postpartum pleural effusion
Collagen-vascular disease

SURGERY Chest wall, Pleura, Mediastinum

o Rheumatoid pleuritic
o SLE
o Wegeners granulomatosis
o Familial Mediterranean fever
Drug Induced
o Nitrofurantoin
o Dantrolene
o IL2
o Procarbazine
o Methotrexate
o Clozapine

Indications for Operative Intervention for Pneumothorax

Persistent Air leak
Recurrent Pneumothorax
First episode in a patient with prior pneumonectomy
Significant hemothorax with chest tube placement
First episode with occupational hazard (airplane pilot,
diver)

Malignant Pleural Effusion

Lung Ca
Breast Ca
Lymphoma
Unresectable tumor
Pleurodesis
o Bleomycin, Tetracyclin, Talcum powder, and
Doxycycline
*Bilateral CTT > pleurodesis > fusion of visceral and pleural
cavity

Pneumothorax

Percutaneous Catheter drainage

Tube Thoracostomy
Video Assist Thoracic Surgery

Spontaneous:
o Primary
Subpleural blebs rupture
o Secondary
COPD
Cystic fibrosis
Spontaneous
Oesophageal rupture
Marfans Syndrome
Eosinophilic granuloma
Metastatic Ca (sarcomas)
Pneumocystis carinii
Asthma
Lung Ca
Acquired:
o Iatrogenic
Central line placement
Pacemaker insertion
Thoracentesis
Needle biopsy
Chest tube malfunction
After laparoscopic surgery
o Barotrauma
o Traumatic
Blunt trauma
Penetrating

Treatment options:
Observation (depending on the amount, usually 10% of
the CXR field) with monitoring, check for any signs and
symptoms (physical and lab findings such as CXR)
Needle Aspiration best used for fluids
4

Tension pneumothorax
Shifting of the midline structure to the contralateral
side/unaffected side.
Clinical patient is dusky, cyanotic, apprehensive,
Tachycardic
Clarification: Needling/needle decompression is done
only in px with tension pneumothorax and it is done as
an emergency procedure not a definitive treatment.
o Purpose is to have enough time in preparation
to CTT insertion or other procedures
Differentiation between Tension pneumothorax and
cardiac tamponade: PE
o Inspection: both with distended neck veins
o Palpation: if with fracture / crepitations
o Percussion: Dull with fluid; Hyperresonant
air (more acceptable/reliable in differentiation
btw TP and CT DURING PE only!) importance
of PE kaya lets all master Bates okay?
o Auscultation no breath sound TP and CT
o Becks triad - both TP and CT, except muffled
heart sounds present only in CT (note: muffled
heart sounds is hard to appreciate in noisy area
such as in the ER or in mass casualty cases)
Empyema
Purulent pleural effusion
Patients of all ages can develop empyema, but the
frequency is increased in older or debilitated patients
Common associated conditions include a pneumonic
process in patients with pulmonary disorders and
neoplasms, cardiac problems, diabetes mellitus, drug
and alcohol abuse, neurologic impairments, postthoracotomy problems, and immunologic impairments
Parapneumonic, post surgical and post traumatic:
o Iatrogenic infections on the pleural space
o Direct infections on the pleural space secondary to
penetrating injuries
o Secondary infections from injury of intra abdominal
organs with diaphragmatic disruption
o Secondary infections of clotted hemothorax
o Hematogenous or transdiaphragmatic lymphatic
spread of abdominal infection
o Postpneumonic empyema secondary to post
traumatic pneumonia, pulmonary contusion.

SURGERY Chest wall, Pleura, Mediastinum

o Fibrothorax trap lung

Needle Thoracentesis (video)
nd
o 2 ICS, MCL of the affected side of the lungs (left or
right)
o Needle catheter is about 2 inches or 5 cm in length
o Needle is removed, leaving the plastic catheter in
place
o Must be followed by prompt placement of Chest
tube on the side of the affected lung
Chest tube Thoracotomy (video)
th
o Site: 5 ICS, Anterior Axillary Line of the affected
th
side (nipple 5 ICS except in some females)
o Anesthesia injection on the skin, subcutaneous
tissue and periosteum of the underlying rib
o Make 2 3 cm transverse incision parallel to the line
of the rib, bluntly dissect the subcutaneous tissue
with scissors, puncture the parietal pleura
o Incision is usually done exactly at the mid or the
upper border of the rib. Make sure that upon
reaching the pleura you are in the superior border of
the rib in order not to damage the neurovascular
bundle of the intercostals located at the inferior
border of each rib.
o Size of Chest tube: for hemothorax the bigger the
better but still depends on the patients ICS size
o Before inserting the tube, place your finger in the
hole you created and rotate your finger 360 to
make sure you are on the pleural space.
o Clamp the proximal and distal ends of the tube
before insertion. The distal clamp will assist you in
the insertion of the tube. All the drainage holes must
be inside the pleural space. Make sure that the
sentinel hole is inside the pleural space. Use your
finger to estimate how far you will insert the sentinel
hole to make sure it is inside the pleural space.
o Position the tube posteriorly and superiorly to allow
drainage in the supine position.
o Connect the end of the tube to an underwater seal
apparatus collection chamber.

Treatment
o Appropriate systemic antibiotics
o Thoracentesis
o Thoracostomy tube drainage
o Thoracoscopy/VATS
o Thoracotomy (decrotication, resection or muscle
flap transposition)

Hemothorax
Spontaneous
o Pulmonary
Bullous empyema
TB
AV malformation
Pulmonary embolus with infarction.
o Pleural
Torn pleural adhesion
Neoplasm
Endometriosis
o Pulmonary neoplasm
Primary/metastatic
o Blood Dyscrasia
Thrombocytopenia
Hemophilia
o Abdominal Pathologic condition
Pancreatic pseudocyst
Splenic artery aneurysm
Hemoperitoneum
o Ruptured Thoracic Aortic Aneurysm
Acquired
o Blunt chest trauma
Rib fractures
o Penetrating chest injury
SW
GSW
HW
Punctured wound
Treatment
o Thoracentesis
o Tube Thoracostomy
o VATS
o Open thoracotomy
When do you open a px with hemothorax? (may be
asked in the exam)
1. CTT drainage of more than 1L (Philippine settings);
ATLS = more than 1.5L (US)
2. Output of more than 200 mL/hr for 3 consecutive
hours (US = 4 consecutive hours)
3. No response to fluid resuscitation
o In general, there is an ongoing massive bleeding
which needs repair.
o Major reason is due to decrease venous return =
hypotension
Complications of Retained Hemothorax
o Abscess formation
o Empyema

(discussion was ended here succeeding notes were from

batch 2018 trans)
CHEST WALL TUMORS
Terms:
Chest Wall Tumors
Can be primary or metastatic
Primary Tumor
Originating from the site itself
Metastatic Tumor
Came from other parts of the body
26 y/o for benign
40 y/o for malignant
2x in male. Breast is not considered a part of the chest
wall
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SURGERY Chest wall, Pleura, Mediastinum

Destruction of the bone

Pathologic fractures and nerve compression
Rare malignant transformation
Tx: Local excision
* Not all pathologic fractures are caused by malignancies.

Presentation:
1. Painless (benign) enlarging mass
2. Painful (malignant) mass with pathologic fracture or
compression of structures
3. Painless but rapidly enlarging
4. Incidental finding

Desmoid Tumors
Now a benign tumor (latest edition of Schwartzs)
Possess alterations in the adenomatous polyposis coli
(APC)/beta-catenin pathway
Locally aggressive tumors
Low grade fibrosarcomas
50% arise in the abdomen
Chest wall most common extra-abdominal site
Together with fibrous dysplasia, there is a history of
trauma
More in female of reproductive age
Predisposing factors:
o History of trauma (25% of cases)
o Gardners Syndrome and Estrogen exposure
Tx: Local wide excision
Radiation may be used for incomplete resection
Usually, there may be recurrence after radiation
therapy. That is why it was included among the
malignant tumors before (old editions)
Usual type of masses encountered in the clinics:
o Lipoma
o Epidermoid cysts
For local excision of the tumor only; for local and wide
excision beyond the mass
The bigger, the wider the excision

Diagnostics
X-ray
CT scan tumor extent, pulmonary metastasis
MRI invasion of contiguous structures
o Best in soft tissues
Bone scan limited role, differentiate solitary
plasmocytoma
from
multiple
myeloma
and
identification of polyostotic fibrous dysplasia
Excision biopsy for small masses of less than 4cms =
may perform simple excision
Incision biopsy for mass greater than 4 cms; If result is
benign, may proceed to simple excision
Cartilaginous tumors excision
Benign Primary Chest Tumors
Chondroma
Most common
Benign cartilaginous tumors (costochondral)
Usually seen on the anterior part of the chest
Seen primarily in children and young adults
Lobulated, well-demarcated osteolytic lesions w/ well
defined sclerotic margins
1-2% transform into chondrosarcoma
Tx: Wide local excision

Malignant Primary Chest Tumors

Surgery is mainstay treatment for sarcomas.
Multimodality therapy for small round cell tumors.
Plasmacytomas treated with high- dose radiation
therapy

Fibrous Dysplasia
30%
Posterior/lateral aspect of rib with history of trauma
2nd and 3rd decade of life
Osteoblast fail to undergo differentiation and
maturation
Monostotic in 70-80%
Polyostotic
Fusiform mass with amorphous or irregular calcification
and cortical thickness
Ground Glass appearance in the central part of the rib
Since they are benign, local excision is warranted

Chondrosarcoma
Most common primary chest wall malignancy
o 50% of all malignant
o 25% of all pulmonary chest wall tumors
30-60 y/o
o 80% from ribs
o 20% from sternum
They usually arise anteriorly from the costochondral
arches
Lobulated mass from medullary portion of rib and
sternum with associated cortical bone destruction
Relatively radio and chemo resistant, that is why,
surgery is still the mainstay of treatment.
5-year survival rate:
o 60% all patients
o 80% without metastatic disease
Local recurrence:
o 20% all patients

Osteochondroma
Often found incidentally as a solitary lesion on
radiograph
Cartilage-capped bony growth with costochondral
junction
Painful benign lesion (as compared to the first two)
2nd decade of life
Pedunculated osseous protuberance with cortical and
medullary continuity with the bone of origin.
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SURGERY Chest wall, Pleura, Mediastinum

o 10% with adequate surgical margins

Metastasis: lung
Poor prognostic factors:
o High tumor grade
o Large tumor size
o Incomplete resection
o Local recurrence
o Presence of metastatic disease
o >50y/o
o Mortally rate is 2 folds higher

Ewings Sarcoma and Primitive Neuroectodermal tumor

(PNET/Akins tumors)
15%
Translocation of chromosomes 11 and 17 in children
and young adults
Small round cell tumors with local and systemic
manifestations
Painful mass with fever and malaise
Chest wall mass with bony destruction and onion peel
appearance
Multimodality, neoadjuvant chemotherapy, wide
excision, radiotherapy, adjuvant chemotherapy
Not all mass with fever is due to infection

Osteosarcoma
Osteosarcomas are the most common bone malignancy;
they represent only 10% to 15% of all malignant chest
wall tumors
Metaphysic of long bones, ribs, scapula or clavicle.
Young adults:
o Painful rapidly growing mass
Elderly:
o Prior irradiation, Pagets disease, or
chemotherapy
o Sunburst pattern of new periosteal bone
formation
o Pre-op chemotherapy then wide excision
o Poor long term survival: 15%
Poor prognostic factors:
o Multifocal disease
o Poor response to pre-op chemotherapy
To shrink the size and to diagnose if
the
tumor
is
sensitive
to
chemotherapeutic drugs
Soft Tissue Sarcoma
50%
Liposarcoma,
malignant
fibrous
histiocytomas,
rhabdomyosarcoma, angiosarcoma and fibrosarcoma
Neoadjuvant: Chemotherapy first followed by wide
excision; 70% 5 yr survival vs. 25 % for wide excision
Reasons for Neoadjuvant Therapy:
o To test whether the lesions are responsive to
chemotherapeutic drugs
o To shrink the tumor so it may be amenable for
a clean excision
High tumor grade, positive surgical margins and
metastatic disease
Desmoid Tumors
Locally aggressive tumors
Low grade fibrosarcomas
50% arise in the abdomen
Chest wall most common extra abdominal site
More in female of reproductive age
Predisposing factors:
o History of trauma (25% of cases)
o Gardners Syndrome and Estrogen exposure
Does not metastasize but with local invasion
Tx: Local wide excision
Radiation maybe used for incomplete resection

Plasmocytoma
10-30%
Rib, clavicle and sternum
Excisional biopsies, imaging studies, serum and urine
electrophoresis to rule out multiple myeloma
Multicystic expansile mass or an osteolytic mass
without expansion
Treatment: High dose irradiation, Presence of lesion
perform biopsy
Differentiate with multiple myeloma
Difference: Plasmocytoma is a solitary lesion while
multiple myeloma is systemic
CHYLOTHORAX
Injury/trauma to the thoracic duct
Chylous pleural drainage (milky, non purulent)
o Due to exogenous fat (chyle)
2 L/day
Treatment
o Chest tube thoracostomy
o NPO
o TPN
o Somatostatin to decrease chyle production
o Ligation of the duct
Chyle drainage:
>500ml/day in adult
>100ml/day in infant
Management
for
chylothorax:
Conservative
management, insert a chest tube and drain it. Place
patient on NPO. Because when you eat, you produce
more chyle and there is a leak. When the leak is small, it
might spontaneously heal. If not, do a open
thoracotomy and ligate the injured part because there
are tributaries. Somatostatin is part of conservative
management because it decreases the secretions
TUMORS OF THE PLEURA
Malignant Mesothelioma
Due to asbestos fibers
o Serpentine larger, snake-like, wavy

SURGERY Chest wall, Pleura, Mediastinum

The bigger they are, the lesser chance

of penetrating the smaller bronchial
tree
o Amphibole smaller, can penetrate smaller
areas
Called crocidolite
o When asked what type of asbestos fiber,
answer crocidolite, not amphibole
20 years latency period
90% with pleural effusion
Diagnosis: Pleural biopsy
o Can be done by open technique or minimally
invasive technique
o In the US, VATS is the preferred method
Treatment:
o Supportive care only
o Surgical resection
But with massive pleural effusion, the
tumor is already nonresectable

th

Sawako Staging System for thymoma (10 edition)

As you increase the number, the poorer the prognosis
of the patient.
What is somewhat difficult to manage for thymoma is
that a patient may have signs and symptoms of
myasthenia gravis but with a small thymus gland. When
you do a surgery, usually they will improve clinically. But
for patients with a huge thymoma, the myasthenia
gravis, when you do the surgery, will seldom respond.
Once you have signs and symptoms, even when you do
surgery, they will usually not respond clinically but you
still have to perform the surgery because the thymoma
is large.

Fibrous Tumors of the Pleura

Usually benign
Single pedunculated mass from the visceral pleura
Cured by complete surgical resection.
If with recurrence they are fatal in 2-5 years
MEDIASTINUM

Review of Anatomy:
The mediastinum is divided into three:
Anterior: posterior to sternum, anterior to heart,
thymus gland
Middle/Visceral: heart, lungs, trachea, major vessels
(visceral organs)
Posterior: esophagus
As a general surgeon, they seldom encounter the
mediastinum except in trauma. But for malignancy, for
tumors, the thoracic surgeons are the one. You can have
lymphoma, thymoma, granuloma.
8

JK