World J Surg (2011) 35:981–984

DOI 10.1007/s00268-011-1035-5

Approach to Empyema Necessitatis

Asli Gül Akgül • Alpay Örki • Tülay Örki •

Mustafa Yüksel • Bülent Arman

Published online: 15 March 2011

Ó Société Internationale de Chirurgie 2011

Abstract multisystem failure and one with squamous cell carcinoma,

Background Thoracic empyema is a collection of pus in
the pleural space. Empyema necessitatis is a rare complica-
tion of empyema, characterized by the dissection of pus
through the soft tissues of the chest wall and eventually
through the skin. We present nine cases of empyema
necessitatis, including etiology, duration, and characteristics
of clinical history, kind of surgery used, and treatment
choices.
Methods In a 4-year period nine patients were treated for
empyema necessitatis. Six were male and 3 female with an
age range of 13–89 years (median = 40 years).
Results Empyema necessitatis was treated with drainage
and antibiotherapy or antituberculosis therapy in three
patients with the diagnosis of tuberculosis or nonspecific
pleuritis. Decortication of the thoracic cavity was used in
three patients successfully. Others were treated with open
drainage. Final diagnoses were tuberculous empyema in five
patients, chronic fibrinous pleuritis in three, and squamous
cell carcinoma in one. Except for two patients, one with
A. G. Akgül (&)
Thoracic Surgery, Kocaeli University Faculty of Medicine,
Kocaeli, Turkey
e-mail: asliakgul@yahoo.com
A. Örki
B. Arman
Thoracic Surgery, Maltepe University Faculty of Medicine,
Istanbul, Turkey
T. Örki
Anesthesia and Reanimation, Kartal Kosuyolu Heart
and Research Hospital, Istanbul, Turkey
M. Yüksel
Thoracic Surgery, Marmara University Faculty of Medicine,
Istanbul, Turkey
all were discharged with no complications.
Conclusion Surgery plays a critical role in the manage-
ment of empyema necessitatis in selected patients. Tube
drainage, open drainage, and decortication are the choices
in variable conditions for obliterating the cavity and
regenerating pulmonary function.
Introduction
An empyema is a collection of pus in a natural body cavity.
One of the most common varieties of empyema is empyema
thoracis, which can be localized at or involve the entire
pleural space [1]. There has been little change in the man-
agement of suppurative lung and pleural disease in the last
two decades. The number of cases of tuberculous empyema
has decreased over the past few decades, but it has not been
eradicated. Although the problem is better managed now
with the development of potent antituberculous medication,
especially in third-world countries, the increasing number of
immunosuppressed patients with HIV and transplantations
and the increasing use of postchemotherapy for cancer have
led to the development of more cases of tuberculosis.
Empyema necessitatis is a rare complication of empy-
ema that is characterized by the dissection of pus through
the soft tissues of the chest wall and eventually through the
skin [1–5]. We present nine cases of empyema necessitatis,
including etiology, time and characteristics of clinical
history, kind of surgery used, and treatment choices.
Materials and methods
In a 4-year period nine patients with the diagnosis of
empyema necessitatis were treated (Table 1). Six were

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Table 1 Patients’ characteristics

Patient Sex Age Side CH Radiology Final procedure Diagnosis DD

1 M 37 R 10 Parenchymal infiltration Decortication Tuberculous pleuritis 7

[10 mm pleural thickness
2 M 26 R 5 \10 mm pleural thickness Tube drainage Chronic pleuritis 9
3 M 75 R 60 [20 mm pleural thickness Open drainage Tuberculous pleuritis –
Calcification
Volume loss
Parenchymal infiltration
Atelectasis
4 M 17 R 11 [10 mm pleural thickness Decortication Chronic pleuritis 8
Atelectasis
5 F 89 L 36 [20 mm pleural thickness Open drainage Chronic pleuritis –
Volume loss
Atelectasis
6 F 40 L 12 [10 mm pleural thickness Decortication Tuberculous pleuritis 10
Parenchymal infiltration
Loculated area
7 M 13 R 1 \10 mm pleural thickness Tube drainage Tuberculous pleuritis 11
Parenchymal infiltration
8 M 85 L 6 \10 mm pleural thickness Tube drainage Tuberculous pleuritis –
Parenchymal infiltration
9 F 55 L 5 [20 mm pleural thickness Open drainage Squamous cell carcinoma –
Atelectasis
CH clinical history (months); DD duration of drainage (days)

and pulmonary tuberculosis 50 years ago. One patient was

treated for pleuritis 5 months prior, and one patient was
treated for pleural effusion 20 years ago. One patient had
undergone a pneumonectomy because of a destroyed lung
due to tuberculosis 25 years ago. Finally, one patient had a
history of spontaneous pneumothorax treated with tube
drainage 6 years ago.

Results

All patients were evaluated carefully and diagnosed clini-

Fig. 1 Physical view of empyema necessitatis (subcutaneus bump)
male and 3 female with an age range of 13–89 years
(median = 40 years). They were admitted to the hospital
with complaints of a subcutaneous bump (Fig. 1) (n = 9),
cough (n = 6), pain (n = 3), sputum (n = 3), fatigue
(n = 2), fever (n = 1), and dyspnea (n = 2).
Two patients had a history of pulmonary infection that
was treated with nonspecific therapy 5 years before pre-
sentation. Two patients had a history of pleural thickness
cally, radiologically, and with needle aspiration. Physical
examination, clinical history, blood and sputum tests, chest
X-rays at the posteroanterior and lateral positions, spi-
rometry, and thorax computed tomography (CT) were
examined carefully. Chest roentgenograms showed opacity
of varying degrees on the affected side. Thorax CTs
demonstrated atelectasis, parenchymal infiltrates, pleural
thickness of varying size, and volume loss in some cases,
and a thick, well-encapsulated, calcified pleural rind and
loculated fluid with a fistula connecting the thoracic cavity
and empyema with subcutaneous tissue in all (Fig. 2).
Fine-needle aspiration was used in all patients and
aspirated material was taken from the cavity filled with the

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Fig. 2 Thoracic CT of empyema necessitatis
loculated fluid. Empyema was demonstrated macroscopi-
cally. Cytological and bacteriological examinations were
done using a routine procedure to determine etiological
factors. We could not identify the specific tuberculosis
agent from the thoracentesis results. Chest tube drainage
was first applied to all patients. Empyema necessitatis was
successfully treated with only tube drainage and antibio-
therapy in two young patients. Duration of drainage was 9
and 11 days, respectively. Surgical treatment of three
patients consisted of partial decortication of the thoracic
cavity. This was successful when the expansion defect
persisted for more than 7 days, since the patients were
young and had no parenchymal pathology or sign of
chronic disease like dense calcific plaques, decrease in
thoracic volume, or destroyed lung. Two elderly patients
were treated with open drainage since they had parenchy-
mal diseases and a long clinical history. One patient died
because of his existing multiorgan failure during observa-
tion with a chest tube, and the last patient who was treated
with open drainage had a final diagnosis of carcinoma and
died from respiratory failure.
We applied open drainage by inserting a soft, large chest
tube following partial resection of one or two ribs. Pleural
irrigation with 500 cc of saline solution was applied to all
patients via the chest tube twice a day, with the aim of
mechanical debridement and facilitating the drainage of the
dense empyema fluid.
Final diagnoses were tuberculous empyema with cul-
tures positive for Mycobacterium tuberculosis in two
patients, tuberculous pleuritis in three patients, chronic
fibrinous pleuritis in three patients, and squamous cell
carcinoma in one patient. In two patients with chronic
pleuritis, Pseudomonas aeroginosa was detected in cul-
tures of surgically resected pleural specimen. Antituber-
culosis drugs were added to surgery in patients with the
diagnosis of tuberculous empyema.
983
All but two patients were discharged from our clinic
with no complications. One of the patients treated with
chest tube drainage died because of serious multiorgan
failure, and another patient with carcinoma died from
respiratory failure.
Tube thoracostomy was the initial procedure used for
treatment, especially in young patients who had minimally
thickened pleura with no parenchymal damage, no spe-
cific medical history, and short duration of disease
(\12 months), and in elderly patients in poor physical
condition. In young patients with chronic disease who had
pleural thickness, tube drainage was not enough, so
decortication was applied to obliterate the space. For
elderly patients with a serious chronic pathology and
parenchymal calcific lesions, tube thoracostomy followed
by open drainage was the preferred treatment modality. A
rigid respiratory exercise program for all patients and
antituberculosis medications for patients with the diagnosis
of tuberculosis were prescribed in addition to the invasive
procedures.
Median follow-up period was 52 months (range =
1–76). In this follow-up period we examined the patients
twice a month for the first 3 months, then once a month up
to a year, then twice a year. In their follow-up controls,
chest X-rays and sputum tests were applied. Antitubercu-
losis therapy with clinical investigation of related patients
was observed by pneumologists. Six patients were alive at
the end of follow-up and there was no recurrence. The
elderly patient treated with open drainage died from car-
diac disorder during his follow-up period.
Discussion
The earliest description of the diagnosis and treatment of
empyema is attributed to Hippocrates who, approximately
2400 years ago, first noted that one could distinguish
between empyema and hydrothorax by auscultation of the
chest, and that proper treatment of empyema required
adequate drainage by means of either an intercostal inci-
sion or rib resection [5, 6]. Infections, both thoracic and
extrathoracic, can invade the normally sterile pleural space
and lead to the development of an uncomplicated para-
pneumonic effusion, a complicated parapneumonic effu-
sion requiring tube thoracostomy for its resolution, or a
pyogenic collection referred to as an empyema. Although
empyema affects patients of all ages and social classes,
they appear to occur more frequently and with more dev-
astating consequences among the elderly and debilitated.
Commonly associated illnesses include neoplasms, pul-
monary diseases, cardiac disorders, diabetes mellitus,
alcoholism, drug abuse, and immunosuppression [7].
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Since the advent of antituberculous chemotherapy and
preventive medicine, tuberculous empyema has become an
uncommon disease, and thus empyema necessitatis has
become extremely rare. Empyema necessitatis occurs when
an encapsulated empyema erodes through the parietal
pleura and discharges its contents outside the pleural cavity
[1, 8]. Tuberculosis is more likely to give rise to empyema
necessitatis than abscesses produced by other pyogenic
organisms because of the chronicity of tuberculous empy-
ema. The most common site of empyema necessitatis is the
subcutaneous tissue of the chest wall. Other sites that are
sometimes involved include the esophagus, vertebral col-
umn, retroperitoneum, pericardium, flank, and groin [2]. A
careful clinical examination with radiologic techniques,
especially CT images, can be very useful in diagnosis.
Surgery plays a critical role in the treatment of empy-
ema in selected patients. In the management of empyema
necessitatis, physical condition, age, duration of symptoms,
etiology, and existing parenchymal pathology play impor-
tant roles in deciding what type of surgery to use. Careful
physical and radiological examinations with a detailed
clinical history and laboratory tests are important. Cyto-
logical and microbiological examinations of the material
aspirated from the cavitary subcutaneous lesion relating
with thorax is the important part of etiological diagnosis.
Use of a chest tube must be the first approach for
treatment. If the expansion failure persists after at least
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7 days after simple drainage, we believe that decortication
is necessary to obliterate the cavity and regenerate pul-
monary function in young patients with no parenchymal
disease, dense calcifications, progressive reduction in vol-
ume, and no comorbidities. We also think that open
drainage in older patients with destroyed parenchyma and a
history of chronic disease is the best surgical procedure.
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