A man with traumatic thoracic conduit injury developed a lymphocele causing upper airway obstruction.

A man with traumatic thoracic conduit injury developed a lymphocele causing upper airway obstruction. Despite drainage of the chylothorax, tracheal compression persisted to be paid to a thoracic duct tear. Operative repair of the tear outcomeed in resolution of the airway obstruction. (Chest 1994; 106:296-97)

Thoracic channel disruption with subsequent chylothorax is a recognized complication of chest trauma.(1)(2)(3)(4)(5)(6)(7) Although the amount of lymph leaking into the pleural space may be large, tube thoracostomy usually stops accumulation of fluid and compression of vital fabrics We describe a patient with a T1 spinal trauma and paraplegia who evolveed life-threatening tracheal compression due to thoracic tube injury despite drainage of chylothorax.

CASE REPORT

A 20-year-old male missionary undergoed a spinal cord injury as a come of an automobile pedestrian accident. forward admission to the hospital in Brazil, he had bilateral hydrothoraces and physical findings consistent with total cord lesion below T1. Bilateral chest tubes were placed and chylothoraces were diagnosed on the milky color of the fluid. Although the drainage from the left chest tube decreased through the next 2 weeks, the right chest tube continued to exhibit 3 to 5 L/d. He was kept fasting after the accident and transferred to this hospital 2 weeks following the injury for management of the thoracic tube injury. Upon arrival, he was begun forward a regimen of intravenous hyperalimentation. Laboratory analysis of the pleural fluid while fasting revealed a WBC of 310/mm(3) with 70 percent lymphocyte still not the presence of chylomicrons. upon postinjury day 21, he required intubation for status asthmaticus triggered according to a drug reaction. A chest comput tomographic (CT) scan showed a 7-cm subdued density mass in the posterior mediastinum extending from the thoracic inlet to the plain of the carina (Fig 1) This mass had pushed the trachea and esophagus anteriorly. Radiographic guided drainage was attempted moreover failed to obliterate the mass. He was extubated 1 week later on the contrary immediately developed evidence of airway obstruction. Fiberoptic bronchoscopy at reintubation revealed dramatic external anteroposterior (4-mm diameter) compression of the trachea extending from just below the vocal cords down to the flat of the carina. The carina was distorted and angled to the right anteriorly. At thoracotomy 2 days later, an 8x10-cm tight lymphocele in the prevertebral space compressing the esophagus and trachea was identified. The fulvous fluid contained no bacteria and a not many lymphocytes. After the lymphocele was drained, a large tear in the thoracic pipe was identified by the welling up of similar fluid. The thoracic pipe was ligated below the plain of the lesion. The patient was extubated the nearest day over a fiberoptic bronchoscope without evidence of tracheal compression. Chest tube drainage decreased dramatically to <300 ml/d and the caesura of his hospital course was unremarkable.

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DISCUSSION

We believe that the tracheal compression that compromised our patient's upper airway was caused at the lymphocele that resulted from the thoracic tube tear. This is supported from the resolution of the upper airway obstruction postoperatively. We believe that this portrays a previously undescribed complication of thoracic conduit injury.

Although unusual, chylothorax following obtuse trauma was mentioned as drawn out ago as 1663 by Longelot and described in detail from Quincke in 1875.(8) Chylothorax associated with thoracic vertebral injury was noted first by way of Krabbell in 1885 and subsequently at others in more recent times.(9)(10) The reason for this association is the anatomic proximity of the thoracic pipe to the thoracic vertebral line The thoracic duct travels onward the right side of the vertebral round pillar in the lower thorax and crosse to the left in the upper third of the chest. Thus, lower thoracic vertebral fractures are associated with right-sided chylothorax while injury to the upper thoracic vertebrae deductions in left-sided effusions.(7) Our patient's bilateral chylothoraces appear to be to be ascribed to the tear occurring in the thoracic canal as it passed over the vertebral column

Chylothorax is typically diagnosed from the characteristic milky color and the demonstration of chylomicrons. Although the pleural fluid we analyzed did not have chylomicrons, we believe the source of the pleural fluid was from the thoracic pipe for the following reasons. First, WBC analysis revealed 70 percent lymphocyte which is characteristic of lymph Additionally, the persistent high compass of pleural drainage is consistent with other reports of chylothorax suitable to a large thoracic pipe tear.(3) The thoracic duct may bring forward several liters a day as demonstrated in patients with therapeutic thoracic pipe cannulation.(11) Second, direct visualization at surgery revealed injury to the thoracic conduit with fluid similar to the chest tube drainage welling up from the conduit Finally, pleural drainage ceased following thoracic conduit ligation. The absence of chylomicrons is to be anticipateed in a patient who has not been enterically f for several days.

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