A Doppler ultrasound scan revealed marked stenosis of the subclavian artery at the outer border of the rib with abnormal flow distal to the narrowing. Within this region of abnormal flow there was evidence of thrombus adherent to the vessel wall.
This patient underwent surgical excision of the cervical rib and had no further symptoms.
A 52-year-old man presented with headaches and shortness of breath. He also complained of coughing up small volumes of blood. Clinical examination revealed multiple dilated veins around the neck. A chest radiograph demonstrated an elevated diaphragm on the right and a tumor mass, which was believed to be a primary bronchogenic carcinoma.
By observing the clinical findings and applying anatomical knowledge, the site of the tumor can be inferred.
The multiple dilated veins around the neck are indicative of venous obstruction. The veins are dilated on both sides of the neck, implying that the obstruction must be within a common vessel, the superior vena cava. Anterior to the superior vena cava in the right side of the chest is the phrenic nerve, which supplies the diaphragm. Because the diaphragm is elevated, suggesting paralysis, it is clear that the phrenic nerve has been involved with the tumor.
A 35-year-old man was shot during an armed robbery. The bullet entry wound was in the right fourth intercostal space, above the nipple. A chest radiograph obtained on admission to the emergency room demonstrated complete collapse of the lung.
A further chest radiograph performed 20 minutes later demonstrated an air/fluid level in the pleural cavity (eFig. 3.117).
Three common pathological processes may occur in the pleural cavity.
If air is introduced into the pleural cavity, a pneumothorax develops and the lung collapses because of its own elastic recoil. The pleural space fills with air, which may further compress the lung. Most patients with a collapsed lung are unlikely to have respiratory impairment. Under certain conditions, air may enter the pleural cavity at such a rate that it shifts and pushes the mediastinum to the opposite side of the chest. This is called tension pneumothorax and is potentially lethal, requiring urgent treatment by insertion of an intercostal tube to remove the air. The commonest causes of pneumothorax are rib fractures and positive pressure ventilation lung damage.
The pleural cavity may fill with fluid (a pleural effusion) and this can be associated with many diseases (e.g., lung infection, cancer, abdominal sepsis). It is important to aspirate fluid from these patients to relieve any respiratory impairment and to carry out laboratory tests on the fluid to determine its nature.
Severe chest trauma can lead to development of hemopneumothorax. A tube must be inserted to remove the blood and air that has entered the pleural space and prevent respiratory impairment.
This man needs treatment to drain either the air or fluid or both.
The pleural space can be accessed by passing a needle between the ribs into the pleural cavity. In a normal healthy adult, the pleural space is virtually nonexistent; therefore, any attempt to introduce a needle into this space is unlikely to succeed and the procedure may damage the underlying lung.
Before any form of chest tube is inserted, the rib must be well anesthetized by infiltration because its periosteum is extremely sensitive. The intercostal drain should pass directly on top of the rib. Insertion adjacent to the lower part of the rib may damage the artery, vein, and nerve, which lie within the neurovascular bundle.
Appropriate sites for insertion of a chest drain are either in the fourth or fifth intercostal space between the anterior axillary and midaxillary anatomical lines.