Affiliations: Springfield, IL
Dr. Hazelrigg is Professor and Chairman of the Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine.
Correspondence to: Stephen R. Hazelrigg, MD, FCCP, Professor and Chairman, Division of Cardiothoracic Surgery, SIU School of Medicine, PO Box 19638, Springfield, IL 62794-9638; e-mail: firstname.lastname@example.org
The article by Alifano et al in this issue of CHEST (see page 1004) revisits a very interesting cause of secondary spontaneous pneumothorax, that of catamenial pneumothorax. As outlined in the article, this is a pneumothorax that is usually right sided and occurs in women within 72 h of menstruation. This has been considered a rare cause of spontaneous pneumothorax but interestingly accounted for 25% of the spontaneous pneumothoraces in women in this series (8 of 32 cases). The questions raised with regard to this disorder are as follows: (1) is the true incidence higher than we previously suspected, and (2) how best should we manage it?
There have typically been described two mechanisms for pneumothorax related to endometriosis. The most common is the movement of endometrial implants to the right diaphragm. They preferentially go there because of the recognized peritoneal circulation up from the pelvis to the right side. These implants then create channels or “holes” through the diaphragm that will allow further implants to move into the chest or allow the transgression of air. The presumed timing of the pneumothorax around menstruation is postulated to occur because of the passage of the cervical mucous plug that allows the retrograde movement of air. Studies have documented pneumoperitoneum at the same time as the pneumothorax.1
There are other possible causes of “holes” developing in the diaphragm (ie, congenital) and theoretically pneumothoraces in women could occur at the same time in any scenario where a “hole” exists through the diaphragm. Hence, not all cases must have evidence of endometriosis. The second and much less frequent cause of endometrial implants in the chest is through venous implants that lodge in the lung itself.
It is possible that the frequency with which diaphragmatic holes contribute to a pneumothorax in women is more prevalent than previously thought. Prior to thoracoscopy, the most common surgical approach was through an axillary thoracotomy, which would not allow visualization of the diaphragm. There is always a 5 to 15% incidence of finding no clear pathology to account for the pneumothorax. Even so, I suspect that this series incidence of 25% is much higher than will be typically found.
Treatment usually involves achieving two goals, closure of the holes and hormone treatment for the endometriosis. The options for closure of the holes is to perform pleurodesis of the chest, resect the portion of the diaphragm involved, or suture closed the individual holes. We must individualize our treatment based on each case. Those with multiple holes over a large area of the diaphragm would seem best suited to pleurodesis (mechanic or chemical, ie, talc). Localized areas may be resected or sutured. Resection using endoscopic staplers should be approached cautiously, as we have had one instance of disruption of the staple line and subsequent herniation. The thick tissue loads are probably most appropriate, and large resection should probably be sutured or patched with a prosthetic material.
Based on this article, it is probably warranted to consider this diagnosis in all young women with spontaneous pneumothorax, especially those on the right side. Evaluation of the diaphragm is easily done with the thoracoscope and if holes or endometrial implants are seen, they should be managed in one of the methods described.
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