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Chapter 80

Non-Neoplastic Thoracic Disease

Rishindra M. Reddy

Key Points

1 Surgical intervention for chest wall tumors depends on the type of lesion and goals of surgery

(resection vs. diagnosis). Reconstruction varies depending on the size of the defect and location on

the chest wall.

2 Thoracic outlet syndrome (TOS) may be arterial, venous, or neurogenic. Neurogenic TOS is the most

difficult to diagnose and surgery for this should be performed in high-volume centers.

3 The primary treatment for a lung abscess is antibiotic therapy.

4 Hemoptysis can be life-threatening from suffocation due to a low volume of blood in the lungs, not

from blood volume loss requiring transfusion.

5 Primary spontaneous pneumothoraces will recur in only 30% of patients after initial treatment.

When they recur, the treatment should include a thoracoscopic evaluation and possible pleurodesis.

6 Transudative pleural effusions should be treated medically, while exudative effusions may need

more intervention. One-quarter of pleural effusions in a community hospital are due to malignancy.

7 Empyema is a part of a spectrum of disease that may be treated early on with drainage alone, but

may require debridement and decortication in more advanced cases.

8 Complications of tracheostomies are usually due to improper placement of the tracheostomy on the

trachea (below the 3rd ring, risking a tracheoinnominate fistula) or to the use of high pressures in

the cuff of the tracheostomy (causing ischemia and long-term stenosis)

9 Mediastinitis is life-threatening and warrants immediate evaluation, antibiotic therapy, and surgical

drainage.

INTRODUCTION

This chapter is meant as resource for the general surgery community and surgery residents with regard

to pathology in the chest. We will cover a wide variety of topics including most noncardiac congenital

disease processes in the thorax.

CHEST WALL ANATOMY

The chest wall is the musculoskeletal structure that contains and protects the structures of the upper

trunk or thorax. There are two openings to the thorax, the superior aperture, or the thoracic inlet, and

the inferior aperture which leads to the abdominal cavity. The head and arms connect to the

intrathoracic structures via the inlet, whereas the diaphragm separates the thoracic and abdominal

cavities at the inferior aperture. The inferior vena cava, esophagus, and aorta all travel to the abdomen

through the diaphragm at levels T8, T10, and T12, respectively.

The sternum, commonly known as the breast bone, is comprised of three parts, the manubrium, the

body, and the xiphoid. The manubrium attaches to the clavicles and the first costal cartilages. The

sternal angle where the manubrium and body connect is called the angle of Louis and is an important

landmark. The second ribs attach to the sternum at this angle and they allow one to count the ribs from

this point down, as the first ribs are not palpable. The body of the sternum contains articular facets for

ribs 2 to 7 and connects to the cartilaginous xiphoid inferiorly. The xiphoid may be bifid and will

eventually ossify in older adults (Fig. 80-1).

The ribs are split into two groups; the upper 7 pairs are the true ribs, with articulations to the

sternum, while the lower 5 pairs are the false ribs. Ribs 8, 9, and 10 connect to each other and the

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