Disorders of the chest wall

Question 1

Epidemiology of spontaneous pneumothorax?

Answer 1

More common in tall, thin, young men (20–40 years) & in smokers

Question 2

What are the causes of spontaneous pnemothorax?

Answer 2

Idiopathic (rupture of apical subpleural bleb)
COPD
Marfan syndrome
Scuba diving
Subclavian catheter insertion

Question 3

Pathogenesis of spontaneous pneumothorax?

Answer 3

Rupture of subpleural bleb → Hole in pleura
Pleural cavity pressure = Atmospheric pressure → Loss of -ve pressure
Lung partially or completely collapses.

Question 4

What are the clinical findings and physical exam features of spontaneous pneumothorax?

Answer 4

Sudden dyspnea, pleuritic chest pain
Tympanic percussion note, absent breath sounds, tracheal deviation towards the collapse.

Question 5

What is the imaging finding of spontaneous pneumothorax?

Answer 5

White visceral pleural line with absent vessel markings peripheral to it.

Question 6

Tx of spontaneous pneumothorax

Answer 6

Observation for <15% pneumothorax or asymptomatic cases.
100% oxygen to reduce nitrogen partial pressure.
Chest tube insertion or thoracoscopy for larger cases

Question 7

What is the primary cause of tension pneumothorax?

Answer 7

Penetrating trauma to the lung.

Question 8

Pathogenesis of tension pneumothorax

Answer 8

Flap-like pleural tear → Air enters pleural cavity but cannot exit.
Increased pressure → Compression atelectasis & compromised venous return.

Question 9

What is the emergency treatment for tension pneumothorax?

Answer 9

Needle decompression at the 2nd intercostal space, midclavicular line.
Chest tube insertion.

Question 10

What are the causes of mediastinitis?

Answer 10

Cardiovascular surgeries.
Esophageal or tracheo-bronchial perforation.
Descending infections from the head and neck.

Question 11

Inflammation of connective tissue that involves mediastinal structures & fills inter-pleural spaces

Answer 11

Mediastinitis

Question 12

What are the causes of mediastinitis?

Answer 12

Cardiovascular surgeries.
Esophageal or tracheo-bronchial perforation.
Descending infections from the head and neck.

Question 13

What are the symptoms of mediastinitis?

Answer 13

Severe chest pain, dyspnea, and fever.

Question 14

What are the causes of esophageal perforation?

Answer 14

Complication of esophagoscopy or insertion of a Sengstaken-Blakemore or
Minnesota tube (for esophageal variceal bleeding)
- Forceful vomiting (Boerhaave syndrome)
- Swallow of caustic substances (e.g. lye solution)
- Certain pills or esophageal ulcers

Question 15

What is the treatment for esophageal perforation?

Answer 15

Parenteral antibiotics (e.g., clindamycin, ceftriaxone).
Surgical repair of esophageal tear and drainage of pleural and mediastinal spaces.

Question 16

Wound drainage or sepsis is the clinical presentation of

Answer 16

Median Sternotomy

Question 17

Diagnosis of Median Sternotomy

Answer 17

Presence of infected fluid in the needle aspirate

Question 18

TX of Median Sternotomy

Answer 18

Surgical drainage, debridement, parenteral broad-spectrum antibiotics

Question 19

Causes of chronic fibrosing mediastinitis

Answer 19

Tbc, Histoplasmosis, Sarcoidosis, Silicosis

Question 20

Pathogenesis of chronic fibrosing mediastinitis

Answer 20

Development of an intense fibrotic process
→ Compression of mediastinal structures → SVC Syndrome or →Tracheal narrowing or → Obstruction of the pulmonary arteries or veins

Question 21

TX of chronic fibrosing mediastinitis

Answer 21

Tbc cases: Anti-Tbc therapy Otherwise, insertion of vascular or airway stents

Question 22

What are the types and causes of pneumomediastinum?

Answer 22

Spontaneous or Secondary (blunt trauma, procedures, or hollow organ perforation).

Question 23

What are the clinical features of pneumomediastinum?

Answer 23

Retrosternal/pleuritic chest pain.
Subcutaneous emphysema.
Dyspnea, cough, fever, dysphagia, & Hamman sign (systolic crackles along left sternal border).

Question 24

What imaging finding is characteristic of pneumomediastinum?

Answer 24

A double line outlining the mediastinum on chest X-ray.

Question 25

What are the complications of pneumomediastinum?

Answer 25

Hypertensive pneumomediastinum → Cardiac and vessel compression → Hemodynamic and respiratory compromise.
Progression to mediastinitis.

Question 26

Predisposing factors of pneumomediastinum

Answer 26

Asthma, interstitial & other lung diseases, tobacco, corticosteroids

Question 27

Precipitating factors of pneumomediastinum

Answer 27

Emesis, cough, defecation, physical exercise, upper airway infection

Question 28

Clinical features of pneumomediastinum

Answer 28

• Thoracic pain (retro-sternal and pleuritic)
• Subcutaneous Emphysema
• Dyspnoea
• Cough
• Fever
• Dysphonia
• Odyno-/ and Dysphagia
• Hamman sign: Systolic crackles in the left sternal border (characteristic sound of “rubbing balloons”)

Question 29

TX of pneumomediastinum

Answer 29

➢ Avoidance of the trigger factor
➢ Oxygen
➢ Bed rest
➢ Antibiotic prophylaxis for Mediastinitis
➢ Chest tube

Question 30

DD of pneumomediastinum

Answer 30

➢ Hypertensive Pneumo-Mediastinum → Cardiac & large vessel compression → Decrease of the venous blood return → Results in haemodynamic & respiratory compromise
➢ Mediastinitis