Diaphragmatic hernia is a defect caused by an abnormal hole in the diaphragm, the muscle that helps in breathing. This opening allows the organs in the abdomen to move up into the chest. Diaphragmatic hernias can be congenital (patients are born with them) and can cause problems soon after birth or later in adulthood. They can also be found following trauma or previous surgery. Symptoms include:
- Shortness of breath
- Pain, pressure, or soreness in the chest
- Difficulty swallowing
- Abnormal heartbeat
The need for surgery will depend on the size and location of the hernia, but most do require surgery because it carries a high risk of future complications.
The mediastinum is the central portion of the chest between the lungs. Any growth found in this cavity is referred to as a mediastinal mass. These growths can be malignant (cancerous) or benign. When the mass is small, a patient may have no noticeable symptoms. Mediastinal tumors are typically found on a chest X-ray taken for other reasons. Symptoms may include:
- Chest pain
- Persistent cough
- Difficulty breathing or wheezing
- Difficulty swallowing
- Night sweats
- Unexplained weight loss
Advanced diagnostic methods are often used to make an accurate diagnosis, including:
- Needle-guided biopsy, using CT scan: Using the CT as a guide, cells or fluid from the mass are collected for biopsy.
- Mediastinoscopy: By making an incision at the top of the breastbone and inserting a thin, lighted tube, a doctor can see inside the chest for any abnormalities. Affected lymph nodes may be removed for further examination in the lab.
- Mediastinotomy: A small incision is made into the side of the breastbone and a biopsy of the suspicious mass is taken. This is usually done under general anesthesia as an outpatient procedure.
Most benign mediastinal tumors require surgical excision in order to alleviate symptoms and prevent further growth.
Paraesophageal hernias occur when a patient's stomach protrudes through the diaphragm into the chest next to the esophagus. The esophagus passes into the stomach through the opening in the diaphragm. Weakened muscles allow the stomach muscles to protrude into the chest, creating the hernia. The diaphragm squeezes stomach acid and other contents back up into the esophagus, causing heartburn and difficulty swallowing.
- Antacid medications to neutralize stomach acid
- H-2 receptor blocker medications to reduce acid production
- Proton pump inhibitors to block acid production and allow time for the esophageal tissue to heal
- Surgeries to make the diaphragm opening smaller, strengthen the esophageal sphincter, or remove the hernia sac.
Surgery is used for those who fail standard medical treatments. Typically, our thoracic surgeons will recommend laparoscopic repair of paraesophageal hernias, which uses a minimally invasive approach.
The pleural space lies between the lungs and chest wall. Pleural effusion is the build-up of fluid in this area. Many underlying benign and malignant conditions can cause this, and both benign and malignant tumors can grow from the pleura.
A higher risk for developing pleural effusions is evident in those who have other medical conditions such as heart failure, liver failure, kidney failure, or severe pneumonia. Asbestos exposure is also a risk factor for developing a pleural tumor.
Symptoms of pleural effusion include:
- Chest pain
- Breathing problems
Several methods may be used to make an accurate diagnosis, including:
- Chest X-ray or CT scan
- Thoracentesis: In this procedure, a doctor will draw the fluid using a needle inserted into the chest. The fluid is examined for potential malignancy (cancer) and other conditions. This procedure is done in the office under local anesthesia.
- Video-assisted thoracoscopic surgery (VATS): During this procedure, a doctor will use a videoscope inserted through two small incisions. This procedure usually requires an overnight stay in the hospital.
- Thoracotomy: A thoracic surgeon will open the chest with a small incision and remove any abnormalities or lymph nodes for further examination in the lab.
For benign cases, treatment may consist of putting medicine into the pleural cavity to keep the fluid from returning. Sometimes a specialist will surgically strip scar tissue from the lung so it can fully expand and fill the pleural cavity. In cases of malignant tumors, treatment may involve removing part of the pleura or lung.
Pectus excavatum is caused when the bones of the ribs and sternum do not form properly, causing a caved-in appearance of the chest. The standard treatment is a surgical procedure that requires a large incision across the chest. However, our thoracic surgeons offer a minimally invasive approach for the least possible scarring.
Thoracic outlet syndrome
Thoracic outlet syndrome (TOS) is caused when the nerves and blood vessels between the base of the neck and armpit are compressed. If the shoulder muscles in the chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels and reducing blood flow to the hands.
This can result from:
- Congenital abnormalities of muscles and ligaments attached to the first rib, or an extra rib
- Traumatic injuries to the neck, such as whiplash
- Injuries of the arm, such as overstretching
- Repetitive activities (assembly line, keyboard typing, etc.)
Thoracic outlet syndrome is a difficult condition to diagnose and treat. Because it shares many of the same symptoms as other upper extremity conditions, such as carpal tunnel syndrome, it is sometimes misdiagnosed.
The most common symptoms of TOS are:
- Numbness and tingling of the fingers
- Pain in the shoulders, neck, and arms
- Muscle spasms in the scapular area — the area between the base of the neck and the shoulders
- Chest pain
- Weakness of the arm and hand
Symptoms become worse with repetitive or overhead activities.
Treatment for TOS includes physical therapy, medications, and weight loss. The goal is to modify postural habits, relieve muscle tension, improve alignment, and increase nerve gliding. Rest, adjustments to how you perform daily activities, oral anti-inflammatory medications, and steroid injections may be recommended.
For patients who have not found relief, surgery may be required.
There are two approaches to TOS surgery:
- Supraclavicular Approach (above the collar bone approach): The thoracic surgeon will attempt to decompress the nerves in the brachial plexus or the adjacent blood vessel. The anterior scalene muscle is usually divided and any bands constricting the nerves or vessels are cut or removed. The first rib (or cervical rib, if present) is removed.
- Transaxillary Approach: The surgeon will access the nerves or blood vessels through the armpit. The remainder of the procedure is performed like the supraclavicular approach.