76. Paraffin plombage    and/or    oil plombage
are, in essence, residue formations of a long-forgotten type of tuberculosis treatment. Both may be summarized as “oleothorax.”
The term “oleothorax” comprises all fat substances and is not restricted to merely “mineral or vegetable“oil.


Oleothoraces
Bild 76

76a. We start with atypical plombages on both sides. CT-slices and reconstructions of one single patient. Go through fast. You will realize later what the typical findings and what the exceptions are.

WGH Schmitt
Bild 76a

76b. You admit it is plombage on both sides. But oleothorax??

Thanks Juliusspital
Bild 76b

76c. Sagittal reconstruction. If you don’t see any problem go on to case 93. Otherwise this case collection will help you to get familiar with the old formations of a long- forgotten tuberculosis treatment.

Complication

76d. The first impression for a problem which is discussed later in detail. We will learn to differentiate between changes in the contents of plombage and in the wall.

Oleothorac, subpleurobronchial Fistula

76e. Now step by step.
Plombage treatment was used in the second quarter of the 20th century.
Oleothorax belongs to the “collapse therapies” and how they were employed in serious to influential caverns of the apex and the upper fields.

What other collapse therapy forms were once in use?
(Click here for the answer)

There was once additionally
- the pneumothorax-therapy as well as
- the thoracoplasty.
The Hein-Kremer-Schmidt book from 1938 provides information about collapse-therapies in lung tuberculosis in the wider Eurpoean field and area. The three parts of this weighty and well-informed handbook deals with the three so-called “collapse therapies” and their benefits as well as their drawbacks. In the USA, it is dealt with in Alexander's “Monography.”

The advantages of oleothorax in comparison with pneumothorax was the unique operation itself. (The air of the pneumothorax had to be renewed quite regularly after some weeks, or indeed after some months).

The advantage of oleothorax vis-a-vis thoracoplasty was the much less serious operation, which did not require the 'resection” of several ribs.


76e. Why must we still recognise these pictures and images today  ?
Even today, we may see these thorax results ; (the therapy has clearly, for some of the younger patients, guaranteed a long survival). What is so important is the detailed knowledge of the various complications: they are rarer than during the long-time observation of the “Light III empyema” (see our cases 45 –75).

A small remnant concerning the DD oleothorax- chron.empyema. Sex differentiation maybe  ? During the oleothorax observation of Obert and Schmitt, 8 women and 4 men were involved; during the empyema-residual predominantly more men than women were involved.

Anamnesis and X-rays make the diagnosis very simple. What is important for the radiographs is as follows: these oleothoraces have become calcified  on the surface area after so many decades. These images actually belong to the differential diagnosis of the calcified thorax shaded regions.

WGH Schmitt,Oleothoraces with diff fat both sides
Check the so-called opinions as regards this particular thorax images. How reliable are they?
(Click here for the answer)

In the two oleothoraces (left and right)

1.The wall calcification is (on the right) typically thin: on the left, uniform and thick. (Finding Number 1 has so many exceptions that one really must discuss them in order to reject or dismiss any of them )
2. The uncalcified layer between Calc. and the inner thoracic wall is thin: the thinner part is to be found in chronical empyema (Light III , see case 40-75).
3. From the shape, it could be (right) – oil, and (left) paraffin. It certainly accords fully with the history.

Take especial note of the thick-calcified residues in both lung areas, the calcified pleura-skin in the right middle area. This continues towards the dorsal area and simulates the shading of the right lung.

77. Two different cases . We must discuss an anatomic detail more specifically.

pleural plombage 2x

The patient (female) on the left had therapy for cavernous tuberculosis of the lung at the age of 47; she underwent  plombage with paraffin (in Europe paraffin was the preferred material)- X-ray examination took place at the age of 91.

Patient right-side received an oleothorax aged 32. This X-ray dates approximately 45 years after. -
It is  probable that oil was employed in this case.

Both cases are typical (burn it into your retina!);
the Findings 1-3 may be confirmed in both cases. Please relate the photographs in a very good light .

Anatomically-speaking, where precisely is this fatty material introduced?
(Click here for the answer)

It is especially important to know that these foreign -body objects material are located extrapleural,
that is to say,
are introduced between the thorax wall (Fascia endothoracica) and the Pleura parietalis.  The foreign material is not to be found within the pleural space itself.
Complications may be caused by dislocation in the pleural space. This dislocation (in addition) ruins the therapeutic effect.

In fact, in the initial phase of this therapy, one started trials and tests so as to provide substance to the pleura space itself. This was an artificial effusion with fat or oil. The method was forsaken in favour of extrapleural plombage. In The USA, this was seemingly not a strict rule.

In America, it seems actually to be the case whereby, in addition to the extra-pleural area, the regular pleural space is used quite extensively. At least 3 US authors from the time-frame pre-1950s  (i.e. Witnesses of that period in history ) position the intra as well as the extra-pleural plombage, both with equal rights and emphasis, side by side.
Hutton (1983) and Deboisblanc (1988) both state and cite this very fact.

As far as the intrapleural method is concerned, oil was the substance of choice (Deboisblanc).
Concerning access to the intrapleural area, there was a far larger incidence of complications compared to the European recorded annals, and so was recorded the result that oil should, as best as possible, be once again removed.

It could well be, that this caused or resulted from a misunderstanding.
The truth is,  that the intrapleural application represented merely an exception. Would the intrapleural access always, time and time again, be quoted , although it was the exception to this rule  ? - -

Literature also sees the juxtapositioning of paraffin and oil. The commonly-held definition tends to promote or further misunderstanding due to the lack of sufficient knowledge:
“Oleothorax means – apodictically – the employment of oil”. Many authors hold, quite mistakenly, this ill-advised and incorrect opinion.
The complete definition runs as follows: oleothoax is the introduction of fatty substances. Paraffin or oil: oleothorax does not exclude paraffin.

From the many substances, with which one has conducted experiments, it is the paraffin-oil that contains the fewest complications. Paraffin may be slightly warmed (and thereby rendered fluid) and introduced into the surgically-modelled space and then retained tight or semitight at body temperature.
This holds good for the European field as well as for certain American authors. J. Alexander (1937) prefers the extrapleural pneumolysis. And it is here that the favourable characteristics of paraffin may be witnessed. It is from Alexander and from Hein, that the two important monographs emanate.

78. CT of a new patient with a pace-maker.
Fibrousing of the pleura in the left upper area after a specific process. Paraffin plombage in the right top upper area.

Densitometry oleothorax
A so-called “Histogram”has shown for a so-called “region of interest (ROI: depicted as a circular white area). What precisely is a histogram?
(Click here for the answer)

Frequency distribution vis-a-vis CT values (= Hounsfield Units = HU) of the volume-elements. Two values are true representatives of this frequency distribution.
Mean = - 160 HU . Whereby the standard deviation is 15 HU.

CT values of paraffin are, therefore, still below or less than fat tissues.
The cavern content is rather darker than the fat cells.
It is simple to understand: to be found in the fatty tissue are also cells (egg white, containing water, approx 50 HU) and not merely fat, as to be found in one such lead substance. A fat cell has accordingly higher HU than this mere fat.

Incidentally, the calcification here is only partially pronounced.

oleothorax both sides, left dense, right fistula
79. Are there plombages with other materials and combinations, rather than with paraffin or oil ? In this new case, what precisely is the plombage content both on the left and the right?
(Click here for the answer)

It is quite apparent that one has done many experiments. The main point however: the substance introduced to compression was easily digestible. So, no surprises at all that we may come across, as an exception, other materials, too.

An unusually thick substance is employed in the left upper area, approx +1000 HU, with a similar thickness to a compacted bone. The reason behind this very highthickness is due, quite likely, to the fact that the oliy / fatty substance was added with iodine salt content. (The same in 76 a-d !)

It is quite often mentioned in literature that Gomenol or Gomonol , an extract from the myrtle tree leaves, is added. The frequency of this mention does not, however, necessarily accord with the significance or meaning. - The effects of this or other additives to the radiation absorption have not been investigated.

Because the left-hand side plombage is a little round or spherical and extends further caudal, that is why the content is probably liquid (see finding 3).

The thickness of the soft tissue layer between the plombage and the inner wall of the thorax is remarcable.

On the right, the plombage wall is unusually thick; the calcification there is quite irregular.

The content of the right-hand side plombage has been coughed up due to a complication (here, a fistula of the bronchial system) ; so, we find air in this artificially-manufactured extrapleural space:
the description as “Pneumothorax” is partly right and partially wrong. One should, therefore, really try to avoid it.
Lengthy, formed structures, which melt with warmth, appear in the sputum area with such fistulas. The paper of Wood calls these “ wax-worms.”

The relative density of the layering between the plombage and the thorax inner wall is remarkable, usually we find fatty tissue in this layer.

Case 79 is similar to case 76 a-e. Just the same  two (very rare) findings but on different sides. We should not loose observations like that.

80. In the CT of case number 79, all of the statements may be doubly-checked. The anatomical relation is very much simpler using CT.

CT Plombage dense material left,pleurobronchial fistule
What may be found in the right side of the "Blombage area" ?
(Click here for the answer)

- Air, above the liquid surface.
- Liquid under the surface: after the CT-values, this could be a protein rich fluid (exsudat).

We do not know when precisely this exsudat originates. Has it its origin (inflammatory mobilization with or without super-infection) already appeared  before the fistula and then continued thereafter  ?

As to the complications:

An earlier complication:
- The plombage can rarely provoke mechanical alterations: upper influx blockages and build-ups, as well as thrombosis of the jugular vein or of the subclavia.

Complications after a few years:

- we have already identified the simplest and the most common complication: namely, the foreign-body reaction of the cavernous wall (accompanied, over the years, by calcification deposits). This fatty material is – because of the period length-  not so inert, as hoped. This complication is to be found, without exception, within the existing oleothorax – existing for over decades. It exists, in summary, in all of the observations of recent times:

- Quite a common reaction  is the sterile or infected exsudat-formation in the plombage.

- This can lead to a perforation.

I observed, upon two occasions, a fistula from oleothorax to the bronchial system. The fluid, oily substances can cause Alveolitis or  so-called mineral-oil-pneumonia.
Regarding a perforation, the oily mass can also reach to the mediastinum (causing so called “Paraffinomata”). The further onset of an “exsudat-granulomatosa-Perikarditis”is very rare.
Haberkorn (1989) reported about the possibility of a ray – induced malignant tumour. In addition, in Meyniard (1980) 's document, we may read about a “ foreign-body sarcoma.”

One may easily conceive how pathogens can achieve secondary penetration in to the vacated plombage capsule. This is given that there is not already, before that penetration, some form of infection, which caused that very penetration. Both can be described as being,
                                  “cause and effect.”