Surgery of Lung Diseases II Staff Members of Cardio-thoracic Surgery Departments Egypt

HYDATID CYST Hydatid pulmonary cysts account for 20% of cases with hydatid disease. The patient complains of breathlessness, cough and expectoration of watery fluid and grape-like skins (cyst rupture). Investigations: CXR: Spherical well-defined opacity,with or without air cap, water-lily appearance (cyst rupture). CT chest. Casoni test: Intradermal test using cyst fluid as an antigen (not reliable). Serological tests: Compliment fixation, indirect hemagglutination, immunoelectrophoresis (more reliable). Surgical Treatment : Enucleation and capetonage i.e.The endocyst is extruded intact and the lung cavity is obliterated by interrupted mattress sutures. Lobectomy (very large cyst). Albendazole (Alzental 200mg tab,10-15mg/kg/day for 28d, rest 2w, repeated2-3cycles)

Life cycle hydatid pulmonary cysts

Life cycle hydatid pulmonary cysts

Pathology

HYDATID CYST

CXR showing hydatid cyst of the right lung (water-lily appearance)

HYDATID CYST – CT chest

HYDATID CYST

Recurrent Multiple Hydatidosis (after Previous surgery 2 years before)

The same patient showing response after the first cycle of 28 days of Albendazole

The same patient showing response after the second cycle of 28 days of Albendazole. Eosinophylia disappeared. The patient noted that she coughed grape skin-like material

BULLA Clinical Picture: Air-filled space within the lung parenchyma. Results from intrinsic destruction of alveolar tissue. Has a fibrous wall. May communicate (open) or not (closed) with the bronchial tree. Clinical Picture: The patient complains of dyspnea (bulla enlarges progressively and compresses normal lung) and/or complications of bulla (pneumothorax, infection, hemoptysis). 

Investigations: Treatment: CXR, CT chest: Define the site, extent of bullae and surrounding lung tissue. Ventilation /perfusion lung scanning: Quantitate functioning lung tissue. Pulmonary function tests: Especially if associated with emphysematous lung. Treatment: Bullectomy. Lobectomy: When the whole lobe is replaced by a large bulla.

CXR - Bulla Right Upper lung

CT Chest: Multiple Bullae

CT Chest lung bullae

Bullectomy

Inhaled FB Nature: Vegetable (peanut, melon seeds, beans, pea..), commoner in toddlers, radiolucent, chemicals producing bronchospasm. Metallic (needles, pins, nails…), commoner in adults especially females wearing Muslim headscarf (hijab), radio opaque, inert. Highest risk between 1 and 3 years old (immature dentition – no molars, poor food control). Right main bronchus is in continuity with the trachea and more vulnerable for FB inhalation.

Clinically: The diagnosis is based on the history from the parents. History of suspected inhaled FB during swallowing of food particles or during playing followed by chocking, attacks of spasmodic cough, stridor, cyanosis and wheezy chest. Inspiratory wheeze is indicative of major air way obstruction.

History of a recent onset of brochospam in a toddler who was previously normal. History of unresolved pneumonia. Localized wheezes on one side with diminished air entry. Diagnostic triad: Unilateral wheeze, Cough & Ipsilaterally diminished breath sounds. Signs of complications. If large stridor and death.

Complications: Repeated chest infections and asthma. Atelectasis, pneumonia and lung abscess. Bronchial stenosis and bronchiectasis. Acute respiratory distress.

Investigations: X ray (PA & lateral views of chest & neck). Atelectasis , Smaller volumes and elevated diaphragm, Hyperinflation and manifestations of complications. Fluoroscopy: Inspiration & expiration: Overinflation (partial obstruction with inspiratory flow) Volume loss with mediastinal shift towards obstructed side (partial obstruction with expiratory flow) CT, MSCT with virtual bronchoscopy. Bronchoscopy should be done even for suspicion.

Lung abscess complicating inhaled FB

Vegetable FB causing complete left lung atelectasis

Vegetable FB right main bronchus

Vegetable FB in Rt lower lobe bronchus with distal atelectasis

Vegetable FB causing hyperinflation of right lung with mediastinal shift to the left

Metallic FB – Syringe needle

Pin for headscarf (hijab), – trachea

Pin for headscarf (hijab) – left main bronchus

Pin for veil – left main bronchus causing distal pneumonia

Pin for headscarf (hijab) in left lower lobe bronchus

Sewing needle – Left main bronchus

Inhaled nail in right main bronchus

Spiral spring in right lower lobe bronchus Radiopaque – spring in right mainstem bronchus

Earring in right bronchus

Safety pin in trachea

Radio opaque bead in trachea

Foreign Body Aspiration Pin in trachea

Foreign Body Aspiration Safety pin in larynx

Treatment I- Endoscopic: Bronchoscopic extraction with or without fluoroscopic guidance. Rigid bronchoscopy under general anesthesia has important advantages over flexible bronchoscopy. Maintains patent airway through which the patient can be better ventilated, with better clearance of secretions. Affords good visualization and grassping of the FB. Allows better control of bleeding. Flexible fiberoptic bronchoscopy is only done in selected adult cases. Not nessicarily a true emergency

Foreign Body Aspiration Age matched appropriate bronchoscopes and a size smaller in case edema or stenosis is encountered Foerign Bodies By Dr.Mohamed Ayyad Consultant Cardio-Thoraic Surgery

II- Surgical Treatment: 1- Thoracotmy and bronchotomy is indicated in cases of impacted distal FB or central FB which is have a smooth glistening surface. 2- Lobotomy sometimes done in cases of complications as distal bronchiectasis.

Neglected FB bronchus with distal bronchiectasis

Treated by segmental resection and extraction of FB