2 A. SKIN AND SOFT TISSUE INFECTION A-1 Abscess1. It is rarely associated with an abnormalchest radiograph.2. Potentially serious infections of thechest wall are subpectoral andsubscapular abscesses.
3 A-1 Abscess3. Local pain with or without swelling, feverand leukocytosis may be present.4. Chest CT scan can identify the problem.5. Prompt drainage and antibiotics therapycan be successful.
4 A-2 Gangrene1. These necrotizing infections are usuallyat the chest tube or thoracotomy site.2. Infections of the head and neck as well asdental manipulation are the source ofnecrotizing infections of chest wall.
5 A-2 Gangrene3. Radical debridement, antibiotics therapy,ventilatory support and delayed closureof the wound are choice of treatment.4. Antibiotics includes penicillin orampicillin, an aminoglycocide, andclindamycin or metronidazole.
6 B. INFECTIOUS CHEST WALL INVASION 1. Drug resistance or superinfection onantibiotics therapy can cause pneumoniaprogressing to infectious chest wallinvasion.2. Acinetobacter calcoaceticus, Actinomycesspecies infections are ever reported.Penicillin therapy is helpful and surgicalintervention may not be necessary.
7 C. EMPYEMA NECESSITATIS 1. It refers soft tissue infection because ofundrained underlying pleural infection.2. It is infrequent today.3. The soft tissue component may requireseparate drainage and resolve if empyemais drained promptly.
8 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 radicalmastectomy will induce the disease.4. The disease presents as cordlike structure.5. No specific therapy is necessary.
9 E. MISCELLANEOUS INFECTIONS 1. Golladay reported 3 benign diseasespresented as chest wall masses.2. These diseases are trichinosis, nodularfasciitis and myositis ossificans.3. The latter 2 were secondary to trauma.
10 E-1 Tietze’s syndrome1. It refers painful, nonsuppurative swellingof the costal cartilages without abnormalhistologic change.2. Its true incidence is unknown.3. Emotional tension is frequentlyassociated with the symptom complex.4. Treatment with compounds containing ibuprofen,hydrocortisone infiltration and surgical removalof the involved area may be helpful.
11 E-2 Costochondritis1. Before 1940, most chondritis was causedby tuberculosis.2. Today, it was followed by surgery, mostcases are sternotomy for cardiacdisease.
12 E-2 Costochondritis3. The 5th to 9th costal cartilages are fused,so infections involve any these segmentsmay dictate a major resection for cure.4. The xiphoid is partially a cartilagestructure, so it can promote bilateralspread of the infection.
13 E-2 Costochondritis5. The primary organisms are. E. coli, S. Pneumo-niae, P. aeruginosa, M.tuberculosis, staphy-lococci, streptococci, and Norcardia.6. Radical resection is the preferred treatment.7. If lower ribs are involved then all fusedsegments must be removed.8. No bare cartilage is left in the infected wound.
14 E-3 OsteomyelitisE-3-1 Sternal osteomyelitis1. It was uncommon today.2. Primary sternal osteomyelitis usuallyoccurs in heroin addicts.3. Secondary sternal osteomyelitis usuallyoccurs after cardiac surgical procedure.
15 E-3-1 Sternal osteomyelitis 4. The risk factors includes DM, lowcardiac output, use of bilateral internalthoracic artery graft and re-operation forpostoperative bleeding.5. The first sign of postoperative sternalosteomyelitis are unstable sternum anddischarge
16 E-3-1 Sternal osteomyelitis 6. In chronic sternal osteomyelitis,extensive sternal and chondral removalwith myocutaneous reconstruction canbe performed.7. Bilateral pectoralis major( PM ) flap is themost common used flap.
17 E-3-1 Sternal osteomyelitis 8. A modified H incision is used to mobilizethe PM muscle with the thoracoacromialartery.9. If possible, the upper manubrium andclavicular attachment is left intact.10. The humeral head of PM muscle is transected.
18 E-3 OsteomyelitisE-3-2 Rib osteomyelitis1. It is diagnosed by local inflammatorysigns and symptoms or persistentdraining sinus.2. Confirmation is made by CXR, and CTscan is not usually necessary.3. Excision of all diseased bones is helpful.
19 E-3 OsteomyelitisE-3-3 Sternoclavicular osteomyelitis1. It usually occurs in addicts and patientswith subclavian catheters.2. Routine CXR is not helpful, even CTscan has little help.3. MRI is more sensitive than CT scan.
20 E-3-3 Sternoclavicular osteomyelitis 4. Radical debridement with removal ofthe sternoclavicular joint, includingsternum, clavicle and the 1st rib.5. It was reported to remove a portion of the2nd rib.6. A flap is made including PM muscle.7. A foreign material or mesh should be avoided.
21 E-3 OsteomyelitisE-3-4 osteoradionecrosis1. It is usually caused by radiation forbreast cancer.2. Wide excision with primary coverage ofthe defect is the choice of treatment.3. Flaps can used, including PM, rectusabdominis and latissimus dorsi flaps.4. A foreign material or mesh should be avoidedif infection is present.
22 F. IMMUNOCOMPROMISED PATIENTS 1. Patients are immunocompromisedbecause of malignancy, malnutrition andHIV infection.2. Chest wall infection of these patients maybe subtle.3. Aggressive debridement and antibioticstherapy may lead to good results.