An unusual case of empyema; intrapleural migration of an inhaled oat head in an adult

Foreign Glass Bodies in Pleura and Pancreas: Systematic Review for Entry Hypotheses and Treatment Options in an Unresolved Case

BACKGROUND

Foreign bodies within the pleura and pancreas are infrequent, and the approaches to their treatment still a subject of debate. There is limited knowledge particularly regarding glass foreign bodies.

METHODS

We present a case involving large glass splinters in the pleura and pancreas, with an unknown entry point. In addition, a systematic review was conducted to explore entry hypotheses and management options.

RESULTS

In addition to our case, our review uncovered eight incidents of intrapleural glass, and another eight cases of glass in other intrathoracic areas. The fragments entered the body through impalement (81%), migrated through the diaphragm after impalement (6%), or caused transesophageal perforation (19%) following ingestion. Eight instances of glass inside the abdominal cavity were documented, with seven resulting from impalement injuries and one from transintestinal migration. There were no recorded instances of glass being discovered within the pancreas. Among the 41 nonglass intrapancreatic foreign bodies found, sewing needles (34%) and fish bones (46%) were the most common; following ingestion, they had migrated through either a transgastric or transduodenal perforation. In all these cases, how the foreign bodies were introduced was often poorly recalled by the patient. Many nonglass foreign bodies tend to become encapsulated by fibrous tissue, rendering them inert, though this is less common with glass. Glass has been reported to migrate through various tissues and cavities, sometimes with a significant delay spanning even decades. There are cases of intrapleural migration of glass causing hemothorax, pneumothorax, and heart and major blood vessels injury. For intrapleural glass fragment management, thoracoscopy proved to be effective in 5 reported cases, in addition to our patient. Most intrapancreatic nonglass foreign bodies tend to trigger pancreatitis and abscess formation, necessitating management ranging from laparoscopic procedures to subtotal pancreatectomy. There have been only four documented cases of intrapancreatic needles that remained asymptomatic with conservative management. There is no direct guidance from the existing literature regarding management of intrapancreatic glass foreign bodies. Consequently, our patient is under observation with regular follow-ups and has remained asymptomatic for the past 2 years.

CONCLUSIONS

Glass foreign bodies in the pleura are rare, and our report of an intrapancreatic glass fragment is the first of its kind. Impalement is the most likely method of introduction. As glass has significant migration and an ensuing complication potential, preventive removal of intrapleural loose glass should be considered. However, intrapancreatic glass fragment management remains uncertain.

Intrapleural Foreign Body: Case Report

The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the airways to the pleural space through a bronchopleural fistula is an exceptional event. We report a case of a pleural empyema consequent to an inhaled wooden skewer. CT scan and bronchoscopy were unable to identify the foreign body, due to its migration in the peripheral airways. The thin and pointed foreign body perforated the visceral pleural surface emerging in the pleural cavity.

Pleuroscopy: therapeutic applications

Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.

Complications following oat head aspiration

We report 5 cases of oat head aspiration in children that resulted in serious complications due to the unidirectional migration of the oat head to the periphery of the lung. The complications included pneumothorax, pneumomediastinum, recurrent hemoptysis, chronic lung disease, bronchiectasis, lobectomy, bronchopleural and bronchocutaneous fistulae, pleural effusion, empyema cavity, and, one not described before, osteomylitis of the rib. Physicians should be aware of the dangers with this particular foreign body aspiration.

A late complication of pectus excavatum repair

We report a late complication of pectus excavatum repair which highlights the importance of a chest X-ray in evaluating chest pain in patients who have had previous chest surgery. It also raises the question of whether or not implanted wires should be electively removed following bony union.

Foreign body aspiration in the adult: an occult cause of chronic pulmonary symptoms

We describe two otherwise healthy subjects with many years sequelae due to lung aspiration. In both, diagnosis was delayed due to lack of history of aspiration. Recurrent pneumonia in the same segment in one, and migratory pneumonia in the other, could have suggested the diagnosis. Review of the literature shows that occult foreign body aspiration poses difficulties in diagnosis and that often a history of aspiration is lacking. However, the recurrent nature and the localization of the pneumonia, as well as the findings during bronchoscopy, should alert the physician to the possibility of foreign body aspiration.