Rib Defects Simulating Pulmonary Cavitation

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Abstract
DEVELOPMENTAL and pathologic changes in the ribs as seen in radio-graphs may simulate cavitation in the underlying lung. The cavities most frequently seen in radiographs of the chest are produced by tuberculous cavitation, the cavitation of an abscess, and air-containing pockets due to broncho-pleural fistulæ. Accurate information as to the presence of cavitation in the lungs is usually of great clinical importance. The shadow of a cavity may be the deciding factor in making a positive diagnosis of tuberculosis in an area of infiltration of doubtful nature. Collapse therapy in tuberculosis is based primarily upon the presence of cavitation. Simple infiltration or consolidation, which has been produced in the lung by a non-tuberculous type of infection, does not call for surgical interference, but if an abscess cavity is found in such an area, operation may be indicated. At the Cleveland City Hospital there have been observed 14 cases in which the radiographs showed changes in the ribs which could readily simulate cavitation if there were a pathologic process present in the underlying lung. Sweaney (1) has made similar observations. The confusing shadows in the cases to be presented are produced by anomalous rib development or by a portion of a rib which has enlarged to enclose an area of bone absorption. This expanded portion of bone casts an annular shadow of increased density, which may be mistaken for the zone of infiltration or fibrosis which often surrounds a cavity in the lung. The central area of lesser density casts a shadow similar to that produced by air in a pulmonary cavity. White (2) has mentioned bifurcation of the ribs, and Fleischner (3) has noted fenestration. In some of the cases to be presented, close inspection will show the true nature of the annular shadows because there are no pathologic changes in the underlying lungs, but the presence of infiltration or fibrosis in these areas could very easily mask the outlines of the expanded ring of bone in the rib and give rise to a false diagnosis of pulmonary cavitation. In cases of doubt, more heavily exposed films from varying angles, or stereoscopic films should aid in determining whether the shadow is produced by a cavity in the lung or by unusual configuration of the rib overlying that area. Case Reports Case 1. A white male, aged In years, was admitted four months after pulmonary tuberculosis had been diagnosed elsewhere. A radiograph of the chest showed densely mottled and streaked shadows in the upper half of the right lung-field and in the lower right hilar area. There was an area of rarefaction 2 cm. in diameter just beneath the right clavicle, which was diagnosed as a cavity in an area of tuberculous infiltration in the lung. Pneumothorax was instituted because of the cavitation. Two months later there was an hemoptysis of two ounces. A few days after the hemoptysis, suspicion arose that the cavity might have been in a rib.

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