Download Infections of the Chest Wall

Infections of the Chest Wall
A. SKIN AND SOFT TISSUE
INFECTION
• A-1 Abscess
1. It is rarely associated with an abnormal
chest radiograph.
2. Potentially serious infections of the
chest wall are subpectoral and
subscapular abscesses.
• A-1 Abscess
3. Local pain with or without swelling, fever
and leukocytosis may be present.
4. Chest CT scan can identify the problem.
5. Prompt drainage and antibiotics therapy
can be successful.
• A-2 Gangrene
1. These necrotizing infections are usually
at the chest tube or thoracotomy site.
2. Infections of the head and neck as well as
dental manipulation are the source of
necrotizing infections of chest wall.
• A-2 Gangrene
3. Radical debridement, antibiotics therapy,
ventilatory support and delayed closure
of the wound are choice of treatment.
4. Antibiotics includes penicillin or
ampicillin, an aminoglycocide, and
clindamycin or metronidazole.
B. INFECTIOUS CHEST WALL
INVASION
• 1. Drug resistance or superinfection on
antibiotics therapy can cause pneumonia
progressing to infectious chest wall
invasion.
2. Acinetobacter calcoaceticus, Actinomyces
species infections are ever reported.
Penicillin therapy is helpful and surgical
intervention may not be necessary.
C. EMPYEMA NECESSITATIS
1. It refers soft tissue infection because of
undrained underlying pleural infection.
2. It is infrequent today.
3. The soft tissue component may require
separate drainage and resolve if empyema
is drained promptly.
D. MONDOR’S DISEASE
1. It is a benign disease with localized
thrombophlebitis of the anterior chest wall,
axilla and breast.
2. Its true incidence is unknown.
3. Most cases are female and radical
mastectomy will induce the disease.
4. The disease presents as cordlike structure.
5. No specific therapy is necessary.
E. MISCELLANEOUS
INFECTIONS
• E-0
1. Golladay reported 3 benign diseases
presented as chest wall masses.
2. These diseases are trichinosis, nodular
fasciitis and myositis ossificans.
3. The latter 2 were secondary to trauma.
• E-1 Tietze’s syndrome
1. It refers painful, nonsuppurative swelling
of the costal cartilages without abnormal
histologic change.
2. Its true incidence is unknown.
3. Emotional tension is frequently
associated with the symptom complex.
4. Treatment with compounds containing ibuprofen,
hydrocortisone infiltration and surgical removal
of the involved area may be helpful.
• E-2 Costochondritis
1. Before 1940, most chondritis was caused
by tuberculosis.
2. Today, it was followed by surgery, most
cases are sternotomy for cardiac
disease.
• E-2 Costochondritis
3. The 5th to 9th costal cartilages are fused,
so infections involve any these segments
may dictate a major resection for cure.
4. The xiphoid is partially a cartilage
structure, so it can promote bilateral
spread of the infection.
• E-2 Costochondritis
5. The primary organisms are. E. coli, S. Pneumoniae, P. aeruginosa, M.tuberculosis, staphylococci, streptococci, and Norcardia.
6. Radical resection is the preferred treatment.
7. If lower ribs are involved then all fused
segments must be removed.
8. No bare cartilage is left in the infected wound.
• E-3 Osteomyelitis
E-3-1 Sternal osteomyelitis
1. It was uncommon today.
2. Primary sternal osteomyelitis usually
occurs in heroin addicts.
3. Secondary sternal osteomyelitis usually
occurs after cardiac surgical procedure.
E-3-1 Sternal osteomyelitis
4. The risk factors includes DM, low
cardiac output, use of bilateral internal
thoracic artery graft and re-operation for
postoperative bleeding.
5. The first sign of postoperative sternal
osteomyelitis are unstable sternum and
discharge
E-3-1 Sternal osteomyelitis
6. In chronic sternal osteomyelitis,
extensive sternal and chondral removal
with myocutaneous reconstruction can
be performed.
7. Bilateral pectoralis major( PM ) flap is the
most common used flap.
E-3-1 Sternal osteomyelitis
8. A modified H incision is used to mobilize
the PM muscle with the thoracoacromial
artery.
9. If possible, the upper manubrium and
clavicular attachment is left intact.
10. The humeral head of PM muscle is transected.
• E-3 Osteomyelitis
E-3-2 Rib osteomyelitis
1. It is diagnosed by local inflammatory
signs and symptoms or persistent
draining sinus.
2. Confirmation is made by CXR, and CT
scan is not usually necessary.
3. Excision of all diseased bones is helpful.
• E-3 Osteomyelitis
E-3-3 Sternoclavicular osteomyelitis
1. It usually occurs in addicts and patients
with subclavian catheters.
2. Routine CXR is not helpful, even CT
scan has little help.
3. MRI is more sensitive than CT scan.
E-3-3 Sternoclavicular osteomyelitis
4. Radical debridement with removal of
the sternoclavicular joint, including
sternum, clavicle and the 1st rib.
5. It was reported to remove a portion of the
2nd rib.
6. A flap is made including PM muscle.
7. A foreign material or mesh should be avoided.
• E-3 Osteomyelitis
E-3-4 osteoradionecrosis
1. It is usually caused by radiation for
breast cancer.
2. Wide excision with primary coverage of
the defect is the choice of treatment.
3. Flaps can used, including PM, rectus
abdominis and latissimus dorsi flaps.
4. A foreign material or mesh should be avoided
if infection is present.
F. IMMUNOCOMPROMISED
PATIENTS
1. Patients are immunocompromised
because of malignancy, malnutrition and
HIV infection.
2. Chest wall infection of these patients may
be subtle.
3. Aggressive debridement and antibiotics
therapy may lead to good results.