Ann Thorac Surg 2008;86:e2. doi:10.1016/j.athoracsur.2008.03.002
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Subcutaneous Presentation of Lung Bulla
Sami Alnassar, MD*,
Sonya Baik, MD,
John Yee, MD
Division of Thoracic Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
* Address correspondence to Dr Alnassar, University of British Columbia, 59-3880 Westminster Hwy, Richmond, British Columbia, V7C 5S1, Canada (Email: dralnassar{at}shaw.ca).
A 60-year-old man with a history of severe emphysema and diffuse bullous disease was transferred to our hospital with a history of spontaneous right pneumothorax and progressive subcutaneous emphysema despite the insertion of two chest tubes. On presentation, the patient complained of shortness of breath and diffuse puffiness in his chest and face. Physical examination revealed no air leak from two previously placed right-sided chest tubes. There was subcutaneous emphysema extending from his face down to his scrotum. A chest roentgenogram showed diffuse subcutaneous emphysema with no pneumothorax. A new chest tube was inserted, which immediately relieved his dyspnea and reduced his subcutaneous emphysema, allowing removal of one of his original tubes. A follow-up computed tomographic scan was performed, which showed a loculated pneumothorax, severe subcutaneous emphysema, and herniation of a large bulla into the subcutaneous tissue through the old chest tube site (Fig 1). On re-examination of his chest, a large bulla was found to be actually protruding thorough his old chest tube site (Fig 2). The following day, the patient was taken to the operating room where thoracoscopic bullectomy and pleurodesis were performed with no complications.
The patient's postoperative course was uneventful and he was discharged 3 days after surgery. We believe that this is the first case report of complete external herniation of a lung bulla through a chest tube site. The large size of opening and straight tract made at the time of chest tube insertion likely contributed to the bulla herniation after removal of the chest tube.
