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Intrapleural foreign bodies
INTRAPLEURAL
FOREIGN BODIES*
JAY IRELAND, M.D. Associate Attending
Surgeon, Chiidren’s Hospital
CHICAGO,
F
OREIGN bodies in the bronchi lungs are rather common but pfeural cavity are comparativeIy
and in the rare.
ILLINOIS
aspirated pus showed type I pneumococcus. On December IO, 1937 a right thoracotomy was performed under novocaine anesthesia and a
Frc. I. Showing the empyema of the right chest with a rubber drainage tube extending into the empyema cavity. Just inferior to the drainage tube are two foreign bodies ftoating on the fluid surface.
The folIowing case is of interest because its diffrcuIt diagnosis and simphcity treatment.
of of
A boy, aged 4 years, entered the ChiIdren’s MemoriaI HospitaI November 16, I937 with a diagnosis of earIy right Iower Iobe pneumonia. Twelve days after admittance the chiId developed a right sided empyema and was treated, on three occasions within the foIIowing nine days, by aspiration of pus. CuItures of the
rubber cyIindrica1 tube inserted into the pIeura1 cavity. The patient improved rapidly after this. A roentgeno~am of the chest taken January 17, 1938 (thirty-eight days after the thoracotomy), reveaIed three foreign bodies in the right pIeura1 cavity at the costophrenic sinus. (Fig. I.) In some of the roentgenograms taken later the bodies Boated on top of the intrapleural fIuid whiIe in others they seemed to be at the bottom of the fluid. There were numerous suggestions as to what these foreign bodies
* From the Surgical Service of Dr. A. H. Montgomery at the ChiIdren’s MemoriaI HospitaI. Read before the Chicago Surgical Society, December g, 1938.
NFW SERIES VOL. XLIX,
wer
beI OId
No.
2
IreIand-IntrapIeuraI
It was thought at first that they might fees of aLdrainage tube which had become Id brok .en. However, an investigation in
Bodies
American
Journal
of I;
337
finaIIy decided to attempt to wa sh them by irrigation. The chiId was laid on his LminvoIved side and normal saline irrige ttion t hrc)ugh
FIG. 2. The Arabic numerats I, 2, 3 and 4 are opposite the obtong areas of zinc oxide ointment upon the skin of the posterior chest. These areas are 0.01, 0.25, 0.5 and I cm., respectively, in thickness.
the operating room where the tube was inserted and in the ward where it might have been removed and repIaced, revealed the fact that onIy new rubber tubing was used in this case. Also upon testing a rubber drainage tube in water it was found that the tube ffoated on top of the water and as the foreign bodies found in this case were sometimes seen at the bottom of the Auid in the films it was hardly possibIe that they were due to retained bits of tubing. No history was given of the presence of any foreign body in the upper respiratory passages which might have penetrated the Iung and viscera1 pleura. It was decided to remove the foreign bodies regardIess of their composition. The original thoracotomy opening was still present and it was beheved that the bodies could perhaps be most easiIy removed through it, possibIy by an endoscope of the type used in bronchoscopic procedures. However, since the bodies seemed to float in some of the roentgenograms it was
the thoracotomy wound was begun. A few seconds Iater the child gave a violent heaving cough and the irrigation Auid gushed from the wound carrying the foreign bodies out of the chest with it. They proved to be masses of zinc oxide ointment. Upon investigation it was found that this ointment had been applied to the skin around the drainage tube because of a dermatitis due to the pus escaping from the empyema. Roentgenograms taken after the irrigation showed the foreign bodies to be absent. The zinc oxide ointment was not considered before the irrigation as a cause of the opaque bodies. In order to show experimentahy whether zinc ointment would cast a shadow in a roentgenogram Iayers of zinc oxide ointment of various thickness were pIaced upon the chest warI externahy and roentgenograms taken 2 shows such a through the chest. Figure roentgenogram with zinc oxide ointment apphed posteriody upon the skin of the chest.
358
AmericanJournalof Surgery
IreIand-IntrapIeuraI
The Arabic numeraIs I, 2, 3, and 4 are opposite the ointment obIongs which are 0.01, 0.25, 0.5, and I cm. respectively in thickness. The oblong of 0.01 cm. thickness is not visible, but the three areas of greater thicknesses are readily seen. The chiId made an uneventfu1 recovery and was discharged from the dispensary May g, 1938. Very few reports of intrapIeura1 foreign bodies were found in the literature. They may be cIassified as (I) those entering the pIeura1 cavity after having been inhaIed, passing through the Iung; and (2) those passing through the chest waI1 from the exterior. Davidsohn,l in 193 r , was abIe to coIIect reports of ten cases in the first group and added one of his own. These foreign bodies incIuded straw, grass, rye, barIey and other grain ears, and artificia1 teeth. His case was that of a deciduous tooth found in the pIeura at necropsy in a woman aged 33 years. As a deciduous tooth is seIdom shed after 12 or 13 years of age, the tooth in Davidsohn’s case was probabIy in the pIeura1 cavity for at Ieast twenty years. Graham2 reported a case in which a chiId aged 18 months aspirated a branch of a tree. Part of the branch was removed at a thoracotomy operation but the remainder was found intrapIeuraIIy at necropsy. In the second group of cases, that of foreign bodies penetrating through the chest waI1 from the exterior, are those due to accidenta penetrations of the chest waI1, missiIes from fire arms, and unfortunate occurrences from surgica1 operation. Andrews3 had six needIes break in doing 58,680 chest punctures. In one of his cases and in one reported by PassuaI,4 an intrapIeura1 broken needle was successfuIIy removed by a thoracoscope. Rubber drain-
AIJGUST,,940
Bodies
age tubes which have notbeen suffIcientIy anchored have not infrequentIy been found in the pIeura1 cavity. Scheide15 removed a rubber drainage tube from the pIeura1 cavity of a man aged 53 who had had the tube inserted seventeen years previousIy for empyema. The patient suffered much during the seventeen years from recurrent attacks of empyema. Jackson and Jackson6 reported four cases of intrapIeura1 rubber drainage tubes foIIowing operations on the chest. Pereira’ successfuIIy removed from the pIeura1 cavity a wood spIinter which entered as the resuIt of a faI1. SUMMARY
Foreign bodies in the pIeura1 cavity are comparativeIy rare. A case herein reported is that of a chiId aged 4 years who suffered from pneumonia and a subsequent empyema. Thoracotomy and rubber tube drainage were instituted. Three foreign bodies within the pIeura1 cavity were Iater seen in roentgenograms. These foreign bodies were ffoated out of the pIeura1 cavity with norma saIine soIution through the thoracotomy wound and proved to be masses of zinc oxide ointment. REFERENCES in the pIeural cavity. Am. J. M. SC., 181: 494-496, 1931. GRAHAM, H. B. Perforation of the pIeura by an inspired foreign body. Calijornia 0 West. Med., 30: 120-121, 1929. ANDREWS, C. H. Thoracoscopic removal of broken aspirating needIe; case. J. Tboracic Surg., 6: 456457, 1937. de la PASCUAL, J., and ABELL~, F. Aphcationes endoscopia pleuraI. Med. ibera, 2: 563-565 1935. SCHEIDEL, H. Uber Fremdkorper im Pleuraraum. Med. Klin., 33: 1641-1643, 1937. JACKSON,C., and JACKSON, C. L. Diseases of the Air and Food Passages of Foreign Body Origin. PhiIadeIphia, 1936. W. B. Saunders Company. PEREIRA, A. G. An unusua1 foreign body in the pIeural cavity. Indian M. Gaz., 63: 20, 1928.
I. DAVIDSOHN, I. A tooth
z. 3.
4. 5. 6.
7.
FOREIGN BODIES*
JAY IRELAND, M.D. Associate Attending
Surgeon, Chiidren’s Hospital
CHICAGO,
F
OREIGN bodies in the bronchi lungs are rather common but pfeural cavity are comparativeIy
and in the rare.
ILLINOIS
aspirated pus showed type I pneumococcus. On December IO, 1937 a right thoracotomy was performed under novocaine anesthesia and a
Frc. I. Showing the empyema of the right chest with a rubber drainage tube extending into the empyema cavity. Just inferior to the drainage tube are two foreign bodies ftoating on the fluid surface.
The folIowing case is of interest because its diffrcuIt diagnosis and simphcity treatment.
of of
A boy, aged 4 years, entered the ChiIdren’s MemoriaI HospitaI November 16, I937 with a diagnosis of earIy right Iower Iobe pneumonia. Twelve days after admittance the chiId developed a right sided empyema and was treated, on three occasions within the foIIowing nine days, by aspiration of pus. CuItures of the
rubber cyIindrica1 tube inserted into the pIeura1 cavity. The patient improved rapidly after this. A roentgeno~am of the chest taken January 17, 1938 (thirty-eight days after the thoracotomy), reveaIed three foreign bodies in the right pIeura1 cavity at the costophrenic sinus. (Fig. I.) In some of the roentgenograms taken later the bodies Boated on top of the intrapleural fIuid whiIe in others they seemed to be at the bottom of the fluid. There were numerous suggestions as to what these foreign bodies
* From the Surgical Service of Dr. A. H. Montgomery at the ChiIdren’s MemoriaI HospitaI. Read before the Chicago Surgical Society, December g, 1938.
NFW SERIES VOL. XLIX,
wer
beI OId
No.
2
IreIand-IntrapIeuraI
It was thought at first that they might fees of aLdrainage tube which had become Id brok .en. However, an investigation in
Bodies
American
Journal
of I;
337
finaIIy decided to attempt to wa sh them by irrigation. The chiId was laid on his LminvoIved side and normal saline irrige ttion t hrc)ugh
FIG. 2. The Arabic numerats I, 2, 3 and 4 are opposite the obtong areas of zinc oxide ointment upon the skin of the posterior chest. These areas are 0.01, 0.25, 0.5 and I cm., respectively, in thickness.
the operating room where the tube was inserted and in the ward where it might have been removed and repIaced, revealed the fact that onIy new rubber tubing was used in this case. Also upon testing a rubber drainage tube in water it was found that the tube ffoated on top of the water and as the foreign bodies found in this case were sometimes seen at the bottom of the Auid in the films it was hardly possibIe that they were due to retained bits of tubing. No history was given of the presence of any foreign body in the upper respiratory passages which might have penetrated the Iung and viscera1 pleura. It was decided to remove the foreign bodies regardIess of their composition. The original thoracotomy opening was still present and it was beheved that the bodies could perhaps be most easiIy removed through it, possibIy by an endoscope of the type used in bronchoscopic procedures. However, since the bodies seemed to float in some of the roentgenograms it was
the thoracotomy wound was begun. A few seconds Iater the child gave a violent heaving cough and the irrigation Auid gushed from the wound carrying the foreign bodies out of the chest with it. They proved to be masses of zinc oxide ointment. Upon investigation it was found that this ointment had been applied to the skin around the drainage tube because of a dermatitis due to the pus escaping from the empyema. Roentgenograms taken after the irrigation showed the foreign bodies to be absent. The zinc oxide ointment was not considered before the irrigation as a cause of the opaque bodies. In order to show experimentahy whether zinc ointment would cast a shadow in a roentgenogram Iayers of zinc oxide ointment of various thickness were pIaced upon the chest warI externahy and roentgenograms taken 2 shows such a through the chest. Figure roentgenogram with zinc oxide ointment apphed posteriody upon the skin of the chest.
358
AmericanJournalof Surgery
IreIand-IntrapIeuraI
The Arabic numeraIs I, 2, 3, and 4 are opposite the ointment obIongs which are 0.01, 0.25, 0.5, and I cm. respectively in thickness. The oblong of 0.01 cm. thickness is not visible, but the three areas of greater thicknesses are readily seen. The chiId made an uneventfu1 recovery and was discharged from the dispensary May g, 1938. Very few reports of intrapIeura1 foreign bodies were found in the literature. They may be cIassified as (I) those entering the pIeura1 cavity after having been inhaIed, passing through the Iung; and (2) those passing through the chest waI1 from the exterior. Davidsohn,l in 193 r , was abIe to coIIect reports of ten cases in the first group and added one of his own. These foreign bodies incIuded straw, grass, rye, barIey and other grain ears, and artificia1 teeth. His case was that of a deciduous tooth found in the pIeura at necropsy in a woman aged 33 years. As a deciduous tooth is seIdom shed after 12 or 13 years of age, the tooth in Davidsohn’s case was probabIy in the pIeura1 cavity for at Ieast twenty years. Graham2 reported a case in which a chiId aged 18 months aspirated a branch of a tree. Part of the branch was removed at a thoracotomy operation but the remainder was found intrapIeuraIIy at necropsy. In the second group of cases, that of foreign bodies penetrating through the chest waI1 from the exterior, are those due to accidenta penetrations of the chest waI1, missiIes from fire arms, and unfortunate occurrences from surgica1 operation. Andrews3 had six needIes break in doing 58,680 chest punctures. In one of his cases and in one reported by PassuaI,4 an intrapIeura1 broken needle was successfuIIy removed by a thoracoscope. Rubber drain-
AIJGUST,,940
Bodies
age tubes which have notbeen suffIcientIy anchored have not infrequentIy been found in the pIeura1 cavity. Scheide15 removed a rubber drainage tube from the pIeura1 cavity of a man aged 53 who had had the tube inserted seventeen years previousIy for empyema. The patient suffered much during the seventeen years from recurrent attacks of empyema. Jackson and Jackson6 reported four cases of intrapIeura1 rubber drainage tubes foIIowing operations on the chest. Pereira’ successfuIIy removed from the pIeura1 cavity a wood spIinter which entered as the resuIt of a faI1. SUMMARY
Foreign bodies in the pIeura1 cavity are comparativeIy rare. A case herein reported is that of a chiId aged 4 years who suffered from pneumonia and a subsequent empyema. Thoracotomy and rubber tube drainage were instituted. Three foreign bodies within the pIeura1 cavity were Iater seen in roentgenograms. These foreign bodies were ffoated out of the pIeura1 cavity with norma saIine soIution through the thoracotomy wound and proved to be masses of zinc oxide ointment. REFERENCES in the pIeural cavity. Am. J. M. SC., 181: 494-496, 1931. GRAHAM, H. B. Perforation of the pIeura by an inspired foreign body. Calijornia 0 West. Med., 30: 120-121, 1929. ANDREWS, C. H. Thoracoscopic removal of broken aspirating needIe; case. J. Tboracic Surg., 6: 456457, 1937. de la PASCUAL, J., and ABELL~, F. Aphcationes endoscopia pleuraI. Med. ibera, 2: 563-565 1935. SCHEIDEL, H. Uber Fremdkorper im Pleuraraum. Med. Klin., 33: 1641-1643, 1937. JACKSON,C., and JACKSON, C. L. Diseases of the Air and Food Passages of Foreign Body Origin. PhiIadeIphia, 1936. W. B. Saunders Company. PEREIRA, A. G. An unusua1 foreign body in the pIeural cavity. Indian M. Gaz., 63: 20, 1928.
I. DAVIDSOHN, I. A tooth
z. 3.
4. 5. 6.
7.