G Model

JINJ 7010 No. of Pages 7

Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Traumatic pulmonary pseudocyst: An underreported entity

B. Phillips* , J. Shaw, L. Turco, D. McDonald, J. Carey, M. Balters, M. Wagner, R. Bertellotti,
D.L. Cornell, D.K. Agrawal, J.A. Asensio
Creighton University School of Medicine, Department of Surgery, Department of Clinical & Translational Science, Omaha, NE, United States

A R T I C L E I N F O A B S T R A C T

Article history: Background: Traumatic pulmonary pseudocysts (TPP) are underreported cavitary lesions of the
Received 6 December 2016 pulmonary parenchyma that can develop following blunt chest trauma. Although the occurrence of
Accepted 11 December 2016 traumatic pulmonary pseudocyst is rare, this condition should be considered in the differential diagnosis
of any cavitary lesion. Awareness of this injury and its clinical significance is important for successful
Keywords: management in order to avoid medical errors in the course of treatment.
Traumatic pulmonary pseudocyst Methods: A literature search was conducted through Medline using the key phrases “traumatic
Traumatic pneumatocele
pulmonary pseudocyst” and “traumatic pneumatocele.” Relevant articles, especially those with focus on
Lung cyst
Lung trauma
diagnosis and management of traumatic pneumatocele in adults, were selected. Due to the scarcity of
Blunt chest trauma literature and lack of Level I evidence on this subject, studies published in any year were considered.
Results: A search of “traumatic pulmonary pseudocyst” and “traumatic pneumatocele” yielded 114
studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were
reviewed. The majority of these were individual case studies; only eight articles were considered large
case studies (greater than eight patients).
Conclusion: Traumatic pulmonary pseudocysts are lesions that occur secondary to blunt chest trauma.
Diagnosis is based on a history of trauma and appearance of a cystic lesion on CT. Accurate diagnosis of
traumatic pulmonary pseudocyst is imperative to achieve successful outcomes. Failure to do so may lead
to unnecessary procedures and complications.
© 2016 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Clinical features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Diagnostic evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Prognosis and follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

* Corresponding author at: Department of Surgery, Department of Clinical and Translational Science, Creighton University School of Medicine, Creighton University Medical
Center, 601 North 30th Street, Suite 3701, Omaha, NE 68131-2137, United States.
E-mail addresses: Bradley.Phillips@alegent.org (B. Phillips), JenniferShaw@creighton.edu (J. Shaw), LaurenTurco@creighton.edu (L. Turco), DanMcDonald@creighton.edu
(D. McDonald), Jason.Carey@alegent.org (J. Carey), Marcus.Balters@alegent.org (M. Balters), Michel.Wagner@alegent.org (M. Wagner), Robert.Bertellotti@alegent.org
(R. Bertellotti), David.Cornell@alegent.org (D.L. Cornell), DevendraAgrawal@creighton.edu (D.K. Agrawal), JuanAsensio@creighton.edu (J.A. Asensio).

http://dx.doi.org/10.1016/j.injury.2016.12.006
0020-1383/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
G Model
JINJ 7010 No. of Pages 7
2 B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Introduction
Traumatic pulmonary pseudocysts (TPP) are rare cavitary
lesions associated with blunt thoracic injury first described by
Fallon in 1940 [1]. Since the original description, these lesions have
been assigned various names in the literature, including traumatic
pulmonary pseudocyst, traumatic pneumatocele, and traumatic
lung cyst [2]. Many authors agree that the term traumatic
pulmonary pseudocyst, proposed by Santos and Mahendra, is
most accurate [3]. The walls of TPPs are formed by interlobar
interstitial connective tissue and lack bronchial elements. True
cysts, on the other hand, are enclosed by epithelial tissue [3].
The etiology of TPP is usually associated with blunt thoracic
trauma. Motor vehicle accidents and falls have been reported as
the most common mechanisms of injury, but little is known about
the prevalence of pseudocyst according to mechanism of injury [4].
Few reports to date have described TPP in association with
penetrating trauma. One report described the formation of a
pseudocyst following guidewire manipulation. A second report
described a pseudocyst that resulted from intraparenchymal chest
tube insertion. All other case reports described the development of
pseudocysts following stab wounds [5]. Barotrauma can also result
in pseudocyst formation. Complications of mechanical ventilation,
although primarily described in infants, can produce single or
multiple air-filled cystic lesions consistent with TPP [6].
Methods
A literature search was conducted through Medline, using the
key phrases “traumatic pulmonary pseudocyst” and “traumatic
pneumatocele.” The selection criteria included studies with a
surgical focus and those that discussed the diagnosis and
treatment of TPP in adults. Recent publications were preferred,
but due to the underreported nature of this lesion, studies
published in any year were considered. Studies that discussed TPP
in children were largely excluded in order to avoid confusion with
post-infectious pneumatoceles.
Results
A search of “traumatic pulmonary pseudocyst” and “traumatic
pneumatocele” yielded 114 articles in total after removing
duplicates. Application of the previously stated inclusion and
exclusion criteria narrowed the selection to 35 articles, which were
reviewed. All studies were classified according to the levels of
evidence. There was a notable lack of Level I evidence; all chosen
studies provide Level III evidence. The majority of these were
individual case studies; only eight articles were large case studies
with greater than 8 patients.
Discussion
Pathophysiology
Traumatic pulmonary pseudocysts are most often seen in
children and young adults. In 1965, Sorsdahl and Powell reported
that 85% of patients with TPP were under the age of 30 [7]. TPP
develops after transmission of compressive forces to the lung
parenchyma secondary to blunt chest trauma [8]. A significant
degree of chest wall compliance, as seen in younger individuals, is
required for TPP formation [9]. By the fourth decade of life,
however, the costal cartilages and posterior costovertebral
ligaments lose their flexibility. In older adults, the result is rib
and sternal fractures rather than pseudocyst formation [10]. TPP
also has a male predominance. Fagkrezos et al [11] suggested that
Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
because males are more often involved in motor vehicle accidents
and falls, they are more likely to be affected.
The literature describes several mechanisms for the develop-
ment of TPP following blunt trauma. Most authors agree that
pseudocysts are produced by shearing forces causing pulmonary
laceration accompanied by the escape of air or fluid into the tissue
[12]. The exact mechanism is unknown, but several theories have
been proposed. Williams and Bonte [13] suggest that concussive
waves produced by blunt trauma create shearing forces that tear
the lung parenchyma. Alternatively, Fagan and Swischuk [14]
speculate that TPP develops following sudden, severe compression
of a segment of the peripheral bronchial tree, which obstructs the
bronchus and transmits an explosive pressure distally. This creates
a “bursting lesion.” These theories led to the proposal of a two-step
inclusive mechanism, which is now widely accepted [15]. First,
compressive traumatic forces increase intrapulmonary pressure
until the parenchyma bursts, producing lacerations. Second,
decompression of the chest and increasingly negative intrathoracic
pressure allow the elastic tissue of the lung to recoil, permitting the
formation of small cavities filled with air or fluid [15]. Each cavity
then continues to grow in size until the pressure within the cavity
is equal to that of the surrounding parenchyma [11].
The mechanism of TPP formation following penetrating trauma
is not well-described and requires further investigation. Some
authors propose that these lesions develop in a “one-way” or
“check-valve” mechanism where air enters a laceration in the
pulmonary parenchyma created by penetrating trauma, such as a
stab wound. If the defect seals quickly, the air becomes trapped and
is unable to escape the pleural space resulting in pseudocyst
formation [8]. TPPs that develop specifically in mechanically
ventilated patients are not heavily researched but are thought to be
a consequence of continuous positive airway pressure [16].
Clinical features
Most traumatic pulmonary pseudocysts present within 24–48 h
following blunt chest trauma [17,18]. The clinical presentation is
variable and ranges from asymptomatic to acute respiratory
distress. Chest pain, dyspnea, cough, and hemoptysis are
commonly reported [19]. Hemoptysis, which is present in up to
56% of cases, may continue for several days [7]. These symptoms
are typical of injury to lung parenchyma and are not specific to
pseudocysts [20]. Patients may present with mild fever and
leukocytosis secondary to absorption of damaged lung tissue
[21,22]. In almost all reported cases, associated injuries such as rib
fractures and pulmonary contusion were present [4]. In the setting
of TPP, acute respiratory failure is related to the presence of an
associated pulmonary contusion [5].
Traumatic pulmonary pseudocysts can be single or multiple,
unilateral or bilateral, and located in any part of the lung. It is well
documented in the literature that the lower lobes are most
frequently involved while the apices are usually spared. Additional
studies have confirmed this finding [6,8,14,23,24]. It is important to
note that the lesion may not be located in the immediate region of
chest wall injury. In some cases of TPP, the traumatic force is
transmitted in a contracoup manner [14]. The velocity of impact and
degree of chest wall displacement may also contribute to the location
of TPP. In an experimental rabbit model, Lau et al [25] demonstrated
that a high velocity impact produces peripheral alveolar injury while
a low velocity, high displacement impact produces central paren-
chymal injury. This theory was supported by Athanassiadi et al [20];
all patients with TPPs were involved in a study of high-speed
accidents, and every TPP developed peripherally.
The size of traumatic pseudocysts reported in the literature
ranges from 1 to 14 centimeters in diameter [5]. Relationships
between size of the lesion and severity of the inciting chest trauma
G Model
JINJ 7010 No. of Pages 7

B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 3

are unclear. However, Melloni et al [23] observed that large

pseudocysts occurred more frequently in those patients with
multiple injuries, bilateral pulmonary contusions, or significant
respiratory involvement. Relationships between size and morbidi-
ty are still unknown, but the risk of developing complications may
be higher in patients with large TPPs.

Diagnostic evaluation

Diagnosis of traumatic pulmonary pseudocyst is based on a

history of blunt chest trauma and specific findings on imaging
studies. Accurate and early diagnosis is the key to a successful
outcome in these patients. The main significance of TPP is that it
must be distinguished from cavitary pulmonary lesions of other
origins, such as abscess, mycosis, malignancy, and others [17].
Failure to accurately diagnose TPP may lead to unnecessary,
harmful, and potentially dangerous diagnostic and therapeutic
procedures. For example, misidentification of the lesion as a
pneumothorax or pneumomediastinum may prompt additional
testing or placement of a thoracostomy tube or drainage catheter.
Fig. 1. Patient A, Trauma Admission Chest X-ray: no apparant significant findings
Perhaps a more severe error would be confusing an uncomplicated
but a TPP is present - see Fig. 2.
TPP with a pulmonary abscess. An abscess requires direct
intervention, while a true TPP does not. Instrumenting a TPP
could potentially seed the sterile space of a TPP thus creating an
infection. Improperly diagnosis a TPP increase the risk of trauma, at which point TPPs decrease in size until resolution.
complications and what was a simple pseudocyst may become a However, some TPPs may enlarge in the first two weeks following
complicated problem. trauma [16,17,30]. This observation may prompt a search for
The typical radiographic presentation of TPP is a round or oval alternative diagnoses, many of which require invasive testing and
shadow that is usually surrounded by pulmonary contusion. Air- treatment. As mentioned above, this exploration may lead to more
fluid levels are often present and thought to be related to bleeding harm than good by increasing the risk of complications.
into the pseudocyst [23]. Only 50% of TPPs are detected on Complete resolution of TPP varies and depends on size and
radiographs when obtained on the day of injury [26]. Pulmonary nature of the lesion. The literature has reported that time to
contusions can mask the presence of TPP for up to 10 days or until radiological resolution averages 3 months but ranges from 4 weeks
the contusion resolves. It is also possible that a TPP may not be fully to 6 months (see Fig. 1) [2]. Larger and more complicated TPPs
developed at the time of imaging, especially in the early hours require a significantly greater time for resolution. [24,31] A study
following a traumatic event. Furthermore, associated injuries may by Chon et al [24] found that lesions filled with blood or greater
not allow chest radiographs to be taken in the upright position, in than 2 cm in diameter have an average resolution time of
which air-fluid levels are more easily identified. According to approximately 5 months.
Melloni et al [23], diagnostic utility of chest x-ray improves by
post-trauma day five, at which time there is resolution of the Differential diagnosis
contusion, complete development of the pseudocyst, and a greater
possibility of obtaining upright radiographs. Regardless, the Differential diagnosis of TPP includes lung abscess, bronchial
literature supports the conclusion that chest radiography may cyst, post-inflammatory pneumatocele, pulmonary sequestration,
not be useful in early diagnosis of TPP (See Fig. 1). tuberculosis, mycosis, herniation of viscera, esophageal rupture,
Computed tomography (CT) is superior to radiography in the
diagnosis of TPP. In a study conducted by Melloni et al [23],
sensitivity of chest radiography in identification of TPP was only
20%, while sensitivity of chest CT was 100%. Other authors have
reported similar findings [26]. Most TPPs are identified inciden-
tally on CT in the course of assessing other thoracic injuries [6]. The
main advantages of CT include earlier identification, visualization
of small lesions, and the ability to identify TPP in the presence of
pulmonary contusion. The typical appearance of TPP on CT is a
round or oval thin-walled cavitary lesion with air-fluid levels (See
Figs. 2–7 ) [27,28].
Several reports published prior to 2003 report an incidence of
TPP of less than 3% among patients with chest trauma or
parenchymal injury. More recent studies report an incidence up
to 10% [Table 1]. However, this is likely a result of more widespread
diagnostic use of CT rather than an increasing occurrence of TPPs.
[23]
Traumatic pulmonary pseudocysts change in size, shape, and
composition within days following trauma [6]. Therefore, serial
imaging studies may help differentiate pseudocysts from other
lesions [29]. Pressure equilibrium between the lesion and Fig. 2. Patient A, Trauma Admission CT Scan of the Chest – Coronal View: Right-
surrounding parenchyma is reached in the first few days post- sided TPP (red circle).

Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
G Model
JINJ 7010 No. of Pages 7
4 B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Fig. 3. Patient A, Trauma Admission CT Scan of the Chest – Axial View: Right-sided
TPP (red circle).
and neoplasm [32]. Some multi-system conditions, such as
Wegener’s granulomatosis, can also result in pulmonary cystic
lesions. A history of trauma is helpful in distinguishing TPP from
these conditions [27]. However, if the lesion does not decrease in
size over time, etiologies other than TPP should be considered [1].
This is particularly true in countries where other causes of cavitary
pulmonary lesions are endemic [2]. A previous chest x-ray may be
helpful in differentiating pseudocysts from pre-existing lesions [1].
Treatment
Treatment of traumatic pulmonary pseudocyst is generally
conservative and primarily involves symptomatic relief. TPPs in the
adult tend to decrease in size and eventually resolve without
specific treatment [26]. In 2006, Chon et al [24] recommended
conservative treatment as long as the lesion decreases in size
within six weeks after trauma. Treatment of symptomatic TPP
includes physiotherapy, bronchial toilet, and postural drainage
[33]. Non-operative management has been widely advocated in the
literature, particularly in the pediatric population. In 2003, Melloni
et al [23] proposed a treatment algorithm for TPP that is still widely
accepted (see Fig. 8).
Use of prophylactic antibiotics remains controversial. Most
studies agree that prophylactic antibiotic therapy is not necessary
unless other injuries are present or surgical procedures are
Fig. 4. Patient B, CT Scan Coronal view – trauma scan; right-sided pneumothorax
(yellow circle); Left-sided TPP (red circle).
Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
performed [6]. Gincherman et al. [34] suggested that sputum
cultures be collected from all patients who have sustained
significant blunt chest trauma, especially in those with hemopty-
sis, pulmonary contusion, or TPP. Culture results can then be used
to guide treatment decisions in the event that infection occurs. In
some cases, antibiotics have been used for simple reassurance;
however, researchers advise against prophylactic antibiotic thera-
py due to the risk of creating resistant organisms. [16,24]
Pseudocyst infection usually manifests late in its clinical course,
and thus prolonged antibiotic prophylaxis could encourage
resistant strains and promote colonization [30]. In any case,
persistent fever, unremitting leukocytosis, or radiographic changes
should prompt suspicion of possible infection, and antibiotic
therapy should then be strongly considered [29].
When conservative management fails surgical intervention
may be required. Early lobectomy should be considered in cases of
extensive lung abscess surrounded by necrotic tissue, failed
bronchoscopic treatment of extensive bleeding, or lack of response
to conservative treatment [29]. The indications for video-assisted
thorascopic surgery (VATS) or even open surgery include persis-
tent air leak, hemothorax due to pseudocyst rupture, significant
enlargement of the pseudocyst, failure of lung expansion, and
compression of surrounding parenchyma. [16,23] In particular,
Melloni et al [23] suggested that pseudocysts larger than six cm or
those that have failed to improve following conservative treatment
are potential candidates for surgical resection. However, it is still
unclear if size or contents of the lesion should influence this
decision. If pulmonary resection is required, parenchyma-sparing
techniques should be used whenever possible [23].
Late thoracotomy has been reported up to six months after
trauma due to pneumonic infiltration and persistent cavitary size
[1]. Romero et al [18] reported a case of giant hemopneumatocele
that resolved spontaneously with conservative treatment. This
observation becomes particularly important in patients with
multiple thoracic injuries who may not be able to tolerate surgery.
Complications
The most important complications of TPP are related to errors in
diagnosis and subsequent complications. With such a large
differential diagnosis for cavitary lesions seen on CXR or CT,
eliciting a history of trauma is vital to making an accurate
Fig. 5. Patient B, CT Scan Coronal View – large left-sided Fluid-Filled TPP (red
circle).
G Model
JINJ 7010 No. of Pages 7

B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 5

diagnosis. Suspicion must be high and the clinical setting must be

appropriate. The clinical findings in traumatic pulmonary pseu-
docyst are vague and nonspecific. Infectious causes may be more
likely to show higher fevers or leukocytosis, but this is not
uniformly true. Identifying associated contusions and/or rib
fractures may be most helpful.
Although rare, complications directly related to properly
diagnosed TPP can occur. These include infection, enlargement,
rupture, and bleeding. CT-guided aspiration may aid in the
diagnosis of secondary infection or abnormal fluid accumulation.
Diagnostic and therapeutic bronchoscopy should be considered for
endobronchial bleeding, thick sputum, large air leak, mediastinal
emphysema, and lobar collapse [33].
The most common complication of traumatic pulmonary
pseudocyst is infection. Due to associated injuries of blunt chest
trauma, infected TPPs carry higher mortality than a typical lung
abscess [35]. Risk of secondary infection is increased by pulmonary
contusion that impairs bacterial clearance [10]. Treatment of
infected TPP is similar to that of a lung abscess. If unremitting signs
of sepsis are present after 72 h of antibiotic therapy, CT-guided
Fig. 6. Patient B, CT Scan Coronal View – large left-sided Fluid-Filled TPP (red
circle). percutaneous drainage should be considered [23].
Disruption of a large bronchus can result in formation of a TPP
that does not resolve and, under certain circumstances, may
enlarge. Continuous positive airway pressure may cause TPP
enlargement and compression of adjacent lung tissue, leading to
hypoxemia and cardiopulmonary instability. One case was
reported in which high airway pressures from mechanical
ventilation may have contributed to enlargement and subsequent
rupture of a TPP. In these cases, closure of the bronchial connection
is required. Treatment options include VATS or open surgery [23].
On rare occasion, a TPP can rupture and cause secondary
pneumothorax. Rupture is uncommon, and its causes are not well-
documented. In cases of TPP-related pneumothorax, conventional
tube thoracostomy is the treatment of choice. The approach is
similar to that used in pneumothoraces with other etiologies:
resection of the lesion with or without obliteration of the pleural
space [23]. Rupture of a small pseudocyst may be clinically
insignificant and resolve spontaneously. Tsitouridis et al [8]
reported one such case that resulted in the formation of a
pneumothorax so small that it was left untreated and resolved
spontaneously without complications.
Hemoptysis is a common feature of TPP, though usually minor
and rarely life-threatening. In the event of massive endobronchial
hemorrhage, bronchoscopy can be attempted as both a diagnostic
and therapeutic tool [23]. Steinhausen et al [30] also emphasized
the value of aggressive coagulation management in cases of severe
hemorrhage. If these measures fail to control the bleeding,
emergency surgery is warranted.

Fig. 7. Patient B, CT Scan Sagittal View – large left-sided Fluid-Filled TPP (red circle).

Table 1
Summary Table of the Literature – TPP Secondary to Blunt Trauma.

Study n = 218 Incidence Age Range Mechanism of Injury Time to Resolution

Cho (2015) 81 8.3% 0–83 yrs MVA (53), fall (26) crush (2) –
Kato (1989) 12 – – – 1–4 mo
Zheng (2011) 10 7–29 yrs MVA (10) 1–6 mo
Luo (2012) 33 9.8% 7–70 yrs MVA (20), fall (9), battery (4) –
Melloni (2003) 10 2.6% 18–44 yrs MVA (10) 3–6 mo
Ulutas (2015) 41 5.3% 12–72 yrs MVA (36), fall (5) 1–5 mo
Chon (2006) 12 – 4–48 yrs MVA (9), fall (2), battery (1) 1 wk-10 mo
Athanassiadi (2003) 14 2.1% 13–24 yrs MVA (14) –
Tsitouridis (2007) 5 4.7% 10 mo-44 yrs MVA (13), fall (2) –

Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
G Model
JINJ 7010 No. of Pages 7
6 B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Fig. 8. Treatment Algorithm: Adapted from Melloni et al.
Prognosis and follow-up
Prognosis for most TPPs is excellent. However, outcome can be
negatively affected by associated injuries of blunt chest trauma or
complications that arise in the course of treatment [17].
Considering cost and prognosis, chest radiography is the imaging
modality of choice following uncomplicated TPPs if initially
apparent on plain films. Chest CT is reserved for monitoring
complicated TPPs or those not clinically appreciable on plain film
[6,23]. At our center, we obtain serial films at three and six months
post-injury to document complete resolution.
Conclusion
Traumatic pulmonary pseudocysts are rare, underreported
lesions secondary to blunt chest trauma. Common symptoms
include chest pain, dyspnea, and hemoptysis. Diagnosis is based on
the appearance of a cystic lesion on imaging and history of recent
trauma. CT is more sensitive than chest radiography in early and
accurate detection of TPP. Conservative treatment is adequate in
most cases, but intervention may be required if complications
arise. Prophylactic antibiotics are usually not required. The
prognosis for most TPPs is excellent, and most lesions spontane-
ously disappear in three months. Follow-up by chest radiography
or alternative imaging is recommended until resolution occurs.
Lack of familiarity with these lesions may lead to errors in
diagnosis and subsequent complications. Therefore, a thorough
understanding of the clinical significance of TPPs is important in
order to avoid misdiagnosis and unnecessary invasive procedures.
Conflict of interest
All authors declare no conflict of interest.
Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
Acknowledgements
This work was supported by Creighton University School of
Medicine, Departments of Surgery and Clinical Science and
Translational Research. The authors thank the staff of the Creighton
University Health Sciences Library for their assistance.
References
[1] Gupta N, George J, Gupta RC, Dixit R. Traumatic pulmonary pseudocyst. Int J
Crit Illn Inj Sci 2013 Apr;3(2):155–8.
[2] Kocer B, Gulbahar G, Gunal N, Dural K, Sakinci U. Traumatic pulmonary
pseudocysts: two case reports. J Med Case Rep 2007;1:112.
[3] Santos GH, Mahendra T. Traumatic pulmonary pseudocysts. Ann Thorac Surg
1978;21:359.
[4] Cho HJ, Jeon YB, Ma OS, Lee JN, Chung M. Traumatic pulmonary pseudocysts
after blunt chest trauma: prevalence, mechanisms of injury, and computed
tomography findings. J Trauma Acute Care Surg 2015;79(3):425–30.
[5] Gulbahar G. Diagnosing traumatic pulmonary pseudocyst. South Med J
2009;102(9):947–8.
[6] Ulutas H, Celik MR, Ozgel M, Soysal O, Kuzucu A. Pulmonary pseudocyst
secondary to blunt or penetrating chest trauma: clinical course and diagnostic
issues. Eur J Trauma Emerg Surg 2015;41(2):181–8.
[7] Sorsdahl OA, Powell JW. Cavitary pulmonary lesions following non-
penetrating chest trauma in children. Am J Roentgenol 1965;95:118–24.
[8] Tsitouridis I, Tsinglou K, Tsandiridis C, Papastergiou C, Bintoudi A. Traumatic
pulmonary pseudocyst: CT findings. J Thorac Imaging 2007;22(3):247–51.
[9] Yang TC, Huang CH, Yu JW, Hsieh FC, Huang YF. Traumatic pneumatocele.
Pediatr Neonatol 2010;51(2):135–8.
[10] Crestanello JA, Samuels LE, Kaufman MS, Thomas MP, Talucci R. Posttraumatic
pulmonary pseudocyst. J Trauma 1998;44(2):401–3.
[11] Fagkrezos D, Giannila M, Maniatis P, Papailiou J, Triantopoulou C. Post-
traumatic pulmonary pseudocyst with hemopneumothorax following blunt
chest trauma: a case report. J Med Case Rep 2012;6:356.
[12] Van Hoorebeke E, Jorens PG, Wojciechowski M, Salgado R, Desager K, Van Schil
P, et al. An unusual case of traumatic pneumatocele in a nine-year-old girl: a
bronchial tear with clear bronchial laceration. Pediatr Pulmonol 2009;44
(8):826–8.
[13] Williams JR, Bonte FJ. Pulmonary damage in nonpenetrating chest injuries.
Radiol Clin N Am 1963;1:439–48.
G Model
JINJ 7010 No. of Pages 7
B. Phillips et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
[14] Fagan CJ, Swischuk LE. Traumatic lung and paramediastinal pneumatoceles.
Radiology 1976;120(1):11–8.
[15] Khan FA, Philips W, Khan A, Seriff NS. Unusual unilateral blunt chest trauma
without rib fractures leading to pulmonary laceration requiring
pneumonectomy. Chest 1974;66:211–4.
[16] Moore FA, Moore EE, Haenel JB, Waring BJ, Parsons PE. Post-traumatic
pulmonary pseudocyst in the adult: pathophysiology, recognition, and
selective management. J Trauma 1989;29(10):1380–5.
[17] Stathopoulos G, Chrysikopoulou E, Kalogeromitros A, Papakonstantinou K,
Poulakis N, Polyzogopoulos D, et al. Bilateral traumatic pulmonary
pseudocysts: case report and literature review. J Trauma 2002;53:993–6.
[18] Romero J, Velmahos GC. Giant posttraumatic hemopneumatocele:
nonoperative management is safe. J Trauma 2000;49(6):1132–4.
[19] Yang PJ, Tsai IT, Liu TH. Traumatic pulmonary pseudocyst. J Pediatr 2015;167
(3):777.
[20] Athanassiadi K, Gerazounis M, Kalantzi N, Kazakidis P, Fakou A, Kourousis D.
Primary traumatic pulmonary pseudocysts: a rare entity. Eur J Cardiothorac
Surg 2003;23(1):43–5.
[21] Ganske JG, Dennis DL, Vanderveer JB. Traumatic lung cyst: case report and
literature review. J Trauma 1981;21:493–6.
[22] Stulz P, Schmitt HE, Haase J, Gradel E. Traumatic pulmonary pseudocysts and
paramediastinal air cysts: two rare complications of blunt chest trauma. J
Trauma 1984;24:850–3.
[23] Melloni G, Cremona G, Ciriaco P, Pansera M, Carretta A, Negri G, et al. Diagnosis
and treatment of traumatic pulmonary pseudocysts. J Trauma 2003;54
(4):737–43.
[24] Chon SH, Lee CB, Kim H, Chung WS, Kim YH. Diagnosis and prognosis of
traumatic pulmonary pseudocysts: a review of 12 cases. Eur J Cardiothorac
Surg 2006;29(5):819–23.
Please cite this article in press as: B. Phillips, et al., Traumatic pulmonary pseudocyst: An underreported entity, Injury (2016), http://dx.doi.org/
10.1016/j.injury.2016.12.006
7
[25] Lau VK, Viano DC. Influence of impact velocity and chest compression on
experimental pulmonary injury severity in rabbits. J Trauma 1981;21:1022–8.
[26] Kato R, Horinouchi H, Maenaka Y. Traumatic pulmonary pseudocyst: report of
twelve cases. J Thorac Cardiovasc Surg 1989;97(2):309–12.
[27] Luo L, Yin L, Liu Z, Xiang Z. Posttraumatic pulmonary pseudocyst: computed
tomography findings and management in 33 patients. J Trauma Acute Care
Surg 2012;73(5):1225–8.
[28] Zheng Z, Pan Y, Guo F, Pan T, Li J. Traumatic pulmonary pseudocyst: a rare but
noteworthy entity. Am Surg 2011;77(8):1098–100.
[29] Yazkan R, Ozpolat B, Sahinalp S. Diagnosis and management of post-traumatic
pulmonary pseudocyst. Respir Care 2009;54(4):538–41.
[30] Steinhausen E, Bouillon B, Yücel N, Tjardes T, Rixen D, Paffrath T, et al.
Nonoperative management of post-traumatic pulmonary pseudocyst after
severe thoracic trauma and hemorrhage by coagulation management, kinetic
therapy, and control of secondary infection: a case report. J Trauma 2007;63
(6):1391–4.
[31] El-Hag-Aly MA, Allam HK. Fate of traumatic pulmonary pseudocyst: factors of
resolution. Asian Cardiovasc Thorac Ann 2015;23(2):176–9.
[32] Voutsas V, Giakamozis A, Lazaridis T, Bitzani M. Post-traumatic lung
pseudocysts: two case reports in ICU patients. J Thorac Dis 2012;4(Suppl
1):74–8.
[33] Celik B, Basoglu A. Posttraumatic pulmonary pseudocyst: a rare complication
of blunt chest trauma. Thorac Cardiovasc Surg 2006;54(6):433–5.
[34] Gincherman Y, Luketich JD, Kaiser LR. Successful nonoperative management of
secondarily infected pulmonary pseudocyst: case report. J Trauma 1995;38
(6):960–3.
[35] Carroll K, Cheeseman SH, Fink MP, Umali CB, Cohen IT. Secondary infection of
post-traumatic pulmonary cavitary lesions in adolescents and young adults:
role of computed tomography and operative debridement and drainage. J
Trauma 1989;29:109–12.