[Thyroid cartilage fracture following sneezing as a cause of spontaneous pneumomediastinum]. / Perelom shchitovidnogo khryashcha vsledstvie chikhan'ya kak prichina spontannogo pnevmomediastinuma.

OBJECTIVE: To evaluate the possible etiological factors of spontaneous pneumomediastinum and to describe a case that was unusual in its etiology: a thyroid cartilage fracture as a result of sneezing. MATERIAL AND METHODS: Six patients (four male, two female, aged 16-82 years) were hospitalized with spontaneous pneumomediastinum diagnosed with a chest X-ray in five patients and 100% with computed tomography. Treatment was symptomatic. RESULTS: The commonest symptoms (cough, shortness of breath, hoarseness) were in four patients. Spontaneous pneumomediastinum developed in three cases as a result of bronchospasm during an attack of bronchial asthma, in one patient after exercise, in one after fibrogastroscopy, in one after sneezing. We report a 30-year-old man who presenting subcutaneous emphysema on the neck, hoarseness, pain when swallowing, hemoptysis developed after sneezing. His computed tomography revealed a pneumomediastinum due to fistula of the fracture of the thyroid cartilage following sneezing while simultaneously obstructing both nostrils. At laryngoscopy, there was a linear hematoma in the resolution stage on the anterior wall of the larynx. He was treated conservatively and recovered rapidly. There are no previous published reports of spontaneous pneumomediastinum following fracture of the thyroid cartilage. CONCLUSION: Fracture of the thyroid cartilage as a result of a sharp rapid increase in airway pressure during a sneeze with blocked nasal passages can be one of the rare causes of spontaneous pneumomediastinum. Avoid closing both nostrils at the same time when sneezing.

[Acute pain syndrome and levels of peripheral blood saturation after various thoracic surgical approaches].

The traumatic effect of surgical approaches was determined by the intensity and duration of pain syndrome and by the degree of lung ventilation disturbances after thoracic surgery. An acute pain syndrome was considered by visual analog pain scale and a blood saturation level for the first 5 days after operation. There were 3 groups, each group consisted of 31 patients. All patients were after thoracotomies, thoracoscopies, rethoracoscopies. Maximal intensity of pain appeared to be after thoracotomies and its degree has been reducing since the first till fifth day (from 8.1 +/- 1.7 to 4.2 +/- 0.9 points). The pain syndrome was reliably less after thoracoscopy (from 5.9 +/- 1.6 to 3.5 +/- 1.4 points). Minimal pain was noted after revideothoracoscopies with the dynamics from 4.0 +/- 2.4 to 2.7 +/- 1.2 points. The rate of blood saturation was more reduced after thoracotomy for the first two days till 92.9 +/- 4.6% and the saturation level became equal on the third day in all groups. Obtained data objectively confirmed the considerably less injury in the case of endoscopic thoracic approaches in comparison with open intervention.

[Optimization of surgical strategy in complications after thoracic operations demanding recurrent surgical interventions].

A frequency of postoperative complications varied from 1-2% after endoscopic thoracal operations to 4-12% after open operations using thoracotomic access. There isn't any common approach to indications and terms of the recurrent endoscopic intervention. An analysis of postoperative complications was made after 2795 thoracothomies and 3632 videothoracoscopies required the recurrent operation in 139 patients (2.2%). The rethoracoscopies were performed on 62 patients (44.6%), thoracoscopies were carried out after thoracotomies in 40 cases (28.8%) and rethoracotomies were in 37 cases (26.6%). The more frequent indication to recurrent operation was bleeding (26.6%), pleural empyema (20.9%), fragmented pleuritis (11.5%). It was shown that thoracoscopy was an alternative to rethoracotomy as the rethoracoscopy in case of nonmassive intrapleural bleeding, clotted hemothorax, postoperative fragmented pleuritis, non-sanitized empyema region, the presence of sequestrums in this area, limited postoperative pleuritis, chylothorax, bronchopleural fistula of the size of 1-2 mm, leakage of the lung, a foreign body in pleural cavity. The lethality consisted of 35.1% after rethoracotomies and it was 12.7% after recurrent endoscopic operations.

[Early rethoracotomies for diseases and chest traumas].

Rethoracotomies were performed on 34 patients operated for diseases and traumas of the chest, diseases of the esophagus which made up 1.3%. Emergency and reoperations were performed on 14 (46%) patients for ongoing intrapleural bleeding, clotted hemothorax and pulmonary bleeding. Emergency and delayed rethoracotomies were performed on 7 patients for non-hermeticity of the lung and incompetence of the bronchus suture, on 5 patients for incompetence of esophagogastroanastomosis, necrosis of the transplant and gastric wall, 3 patients for chylothorax not-arrested conservatively, 2 patients for gangrene of the residual lung lobe due to disturbed venous outflow. Postoperative complications resulted in death of 12 (37.5%) patients. Causes of lethal outcomes were purulent complications (pleural empyema, mediastinitis, sepsis, polyorganic insufficiency--in 5), massive blood loss with the development of coagulopathy (in 4), pneumonia of the only lung after pulmonectomy (in 2), pulmonary embolism (in 1). In addition, torsion of the residual lung lobe, foreign body in the pleural cavity can be considered as indications for rethoracotomy.

[Possibilities of thoracoscopy in the diagnosis and treatment of complications after thoracotomy].

Reoperations were fulfilled on 71 patients (2.73%) after 2576 thoracotomies for diseases and injuries of the chest, rethoracotomies were fulfilled on 34 patients, in 37 patients the interventions were fulfilled endoscopically. The indication for thoracoscopy were continuing intrapleural bleeding, fragmented pleurisy due to pleural empyema, not arrested chylothorax, foreign body (drainage tube). Nine patients died (24.3%). Lethality was one third less as compared with rethoracotomy.

[Causes and results of repeated videothoracoscopy].

For 7 years videothoracoscopies for diseases and traumas of the chest were fulfilled in 2075 patients, abscessoscopy in 27 patients. Repeated videothoracoscopies were fulfilled in 41 (2%) patients operated for spontaneous pneumothorax, pleural empyema, exudative pleurisy and injuries to the chest due to recurrent hydropneumothorasx, prolonged abundant release by drainage, bleedings by drainage or formation of clotted hemothorax, not effectiveness of sanation, of the empyema cavity, reabscessoscopy - in 2 patients. Revideothoracoscopies were divided into groups with the presence of drainages or removed drainages according to the terms - into emergent (on the first day, immediately after the development of complications), urgent (from 2 to5 days), postponed (from 6 to 15 days), and late (more than 15 days). In 4 cases the conversion to minithoracotomy had to be done due to continuing bleeding, the absence of lung hermetism. All patients with spontaneous pneumothorax, pleuritis and chest trauma recovered. Lethal outcome was in 1 (2.4%) case from lung artery thromboembolism. It was concluded that revideothoracoscopy was an alternative thoracotomy of full value in reinterventions.