2. Bronchiectasis
is a persistent, general or local dilation of the bronchial
wall, generally beyond the subsegmental level
Pathology Three major patterns of dilatation are
recognized macroscopically:
Cylindrical ,Saccular &Varicose
Site: the left lung is involved more often than the right
The left lower lobe was most frequently involved
3. Etiology:
A-Congenital
Congenital bronchial stenosis
Pulmonary sequestration
Immotile cilia syndrome (Kartagener's syndrome)
Bronchiomalasia
Cystic fibrosis
B-Acquired:
External bronchial compression: Usually by an enlarged LN.
Measles
Pertussis
TB
Internal bronchial occlusion
Inhaled foreign body
Tumor
Retained thick purulent secretions
4. Clinical presentation
1-A persistent productive cough of purulent sputum
2-Hemoptysis
3-repeated chest infection
4- Pleuritic chest pain
5- Dyspnea
6-Associated symptoms include: fever, weight loss,
anorexia and anemia.
Physical examination:
Cyanosis
Clubbing
coarse crepitations & wheezing
Dullness over the affected area
5. Investigations:
1-CXR : the common findings are
increased lung markings,
atelectasis,
air-fluid levels
Cavities which fill and empty on serial CXR
Honey-comb pattern: areas of destroyed lung with compensated
overinflated adjacent parenchyma
2-CT scan: is the method of choice, it shows Bronchial
dilatation and wall thickening
3-Bronchoscopy : presence or absence of foreign body,
bronchial stenosis or tumor
bronchial wash for culture
tracheobronchial toilet
4-PFT ( spirometery ) : restrictive pattern
6.
7. Treatment:
A-Medical treatment
Prevention and control of infection: by proper usage
of antibiotics
Mechanical removal of purulent secretions by:
Cough and chest physiotherapy
Postural drainage
Bronchoscopy
B- Surgical treatment
Indication:
1-Disease progress despite medical treatment
2-Recurrent episodes of chest infection
3-Frequent episodes of hemoptysis
8. The Mediastinum
It is the central cavity of the thorax bounded by:
Thoracic inlet superiorly
Diaphragm Inferiorly
Sternum anteriorly
Vertebral column posteriorly
Pleural cavity laterally
Anatomy:
Clinically divided by imaginary lines into
Anterio-superior mediastinum:
It is anterior to the pericardium over the great vessels.
It contains:
The thymus gland
Aortic arch and branches
Great veins
Fatty areolar tissue
9. Middle mediastinum:
is bordered anteriorly by the anterior pericardial reflection and posteriorly by the
posterior pericardial reflection.
The middle mediastinal contents include
the heart,
pericardium,
phrenic nerves,
tracheal bifurcation and main bronchi,
hila of each lung,
Posterior mediastinum:
bounded anteriorly by the pericardium and posterior pericardial reflection and dorsal
spine posteriorly
The posterior mediastinum contains
the esophagus,
vagus nerves,
sympathetic nervous chain,
thoracic duct,
descending aorta,
azygous and hemiazygous systems,
paravertebral lymphatics .
10.
11. Thymoma
Most common neoplasm of the antero-superior
mediastinum and most common mediastinal mass
Peak incidence 40-60 years of age
Pathology: Histologically classified into
1-Predominantly lymphocytic
2-Predominantly epithelial
3-Mixed (most common 50%)
12. Staging
Masaoka classification:
Stage I: encapsulated tumor.
Stage II:
IIa : microscopic transcapsular invasion
IIb: macroscopical invasion into fatty tissue
Stage III: invasion to the great vessels and lung.
Stage IV:
IVa: pleural or pericardial dissemination
IVb: lymphatic or hematogenous metastasis
13. Clinical presentation:
1- 1/3 of patients are asymptomatic
2-Local mass effect: cough, dyspnea, hoarseness of
voice, dysphagia,hemoptysis, SVC obstruction
3-Systemic syndromes (usually autoimmune):
A-Myasthenia
B-Aplastic anemia
C-Cushing's syndrome
D-Hypo or hyper gammaglobulinemia
E-Rheumatoid arthritis
14. Diagnosis:
Electromyography ( EMG )
Tensilon test
Acetyle choline receptor antibody titer
Imaging
CXR, CT, MRI.
Tensilon test: transient increase in muscle strength after
administration of short acting anticholinesterase such as
edrophonium (tensilon)
EMG: abnormal loss of muscle contraction strength after
multiple repetitive stimulation of the appropriate motor
nerve → positive for MG
CXR & CT: it appears as a small well circumscribed mass or
a bulky lobulated mass confluent with adjacent
mediastinal structures
15.
16. Treatment of thymoma:
Surgical resection is the therapy for thymoma whenever
possible without removing or injuring vital
structures
Best approach is through VATS or a median sternotomy
Treatment modalities:
Stage I → thymectomy alone
Stage II & III → thymectomy + radiotherapy
Stage IV → multiagent therapy (surgery +
radiotherapy + chemotherapy)
Recurrent disease → multiagent therapy (surgery +
radiotherapy + chemotherapy)
17. Postoperative care:
1-ICU
2-ETT should be present and artificial ventilation
continued probably for the first 24 hours.
3-Aggressive attention to pulmonary status:
Chest physiotherapy
Bronchodilators
Bronchoscopy + endobronchial suction
4-Early ambulation
18. Hydatid disease of the lung is caused by the tape worm (Taenia
Echinococcus ) or (Echinococcus Granulosis) .
Hydatid cyst means cyst full of water .
Life cycle
It has a life cycle between dogs & sheep . Parasites in the
elementary tract of the dog shed ova that excreted in the dog
faeces , contaminated the food of the sheep in which hydatid
cyst will develops in the viscera . Including the lung .Infected
sheep when slaughtered and its entrails are eaten by dogs , the
life cycle is completed .When a human being hands or food
become contaminated with canine fecal material containing ova
which will be ingested . The parasitic larva burrow through the
gastric mucosa and are carried to the liver in the portal venous
circulation where most of them filtered out to form hydatid cyst
of the liver ,
19. some escape the liver &lodge in the lung to form
one or more hydatid cyst which grows slowly or
rapidly over years . The cyst consists of a
germinal layer & cyst fluid containing broad
capsule & scoleses . A cellular white hyaline
layers are laid down outside the cyst so that the
cyst is enclosed by a laminated cyst membrane .
As the cyst enlarged , it usually reaches the
pleural surface . Compression of the lung tissues
produces a thin fibrous layer of atelectatic lung
tissue around the cyst (capsule , pericyst or
adventia)
20. Clinical Manifestation
A-Asymptomatic Any smooth homogenous
opacity of uniform density with clear cut border
and little or no reaction around it on a chest X-ray
is a hydatid cyst unless proved other wise .
B- Symptomatic: cough & haemoptysis due to
rupture of the cyst , or it can lead to severe
dyspnea , or asphyxia ,or a hyper sensitivity
reaction , If the cyst get infected ,it will lead to
formation of lung abscess or bronchiectatic
changes
21. Investigation
Routine blood investigation include
CBC which show hyper eosinophilia
serological tests, IgG ELISA and indirect
hemagglutination assay (IHA)
Radiological Findings CXR CT Chest
1-Smooth homogenous opacity (Intact H.C).
2-Partial rupture (per vesicular pneumocyst).
3-Complete rupture (Water –lilly sign) .
4-Formation of lung abscess(Air –fluid level) .
5-Completely coughed out cyst (empty cavity )
6-Rupture into the pleura (hydropneumothorax) If the cyst get
infected ,it will lead to formation of lung abscess or
bronchiectatic changes
22.
23.
24. Treatment
Surgical
A-Inoculation means to remove it intact.
B-Aspiration &evacuation technique
C-Wedge resection or excision of the cyst with
adjacent lung tissue.
D-Segmentectomy,Lobectomy or
Pneumonectomy (rare ).
Medical
for those with disseminated disease and unfit for
surgical treatment the drug used is Albendazol or
Mebindzol
