Bronchial Fistula: Rare Complication of Treatment with Anlotinib / 中国肺癌杂志

BACKGROUND@#Anlotinib is a newly developed small molecule multiple receptor tyrosine kinase (RTK) inhibitor that was approved for the treatment of patients with lung cancer in China. We aim to report 3 cases of rare complication of anlotinib-bronchial fistula (BF) during the treatment of lung cancer patients and summarize the possible causes.@*METHODS@#We collected three patients who developed BF due to anlotinib treatment, and conducted a search of Medline and PubMed for medical literature published between 2018 and 2020 using the following search terms: "anlotinib," "lung cancer," and "fistula."@*RESULTS@#Our literature search produced two case reports (three patients) which, in addition to our three patients. We collated the patients' clinical characteristics including demographic information, cancer type, imaging features, treatment received, risk factors for anlotinib related BF, and treatment-related outcomes. The six patients shared some common characteristics: advanced age, male, concurrent infection symptoms, diabetes mellitus (DM), advanced squamous cell and small cell lung cancers, centrally located tumors, tumor measuring ≥5 cm in longest diameter, and newly formed tumor cavitation after multi-line treatment especially after receiving radiotherapy. Fistula types included broncho-pericardial fistula, broncho-pleural fistula, and esophago-tracheobronchial fistula. Six patients all died within 6 months.@*CONCLUSIONS@#Although anlotinib is relatively safe, it is still necessary to pay attention to the occurrence of BF, a rare treatment side effect that threatens the quality of life and overall survival of patients. Anlotinib, therefore, requires selective use and close observation of high-risk patients.

Communicating Bronchopulmonary Foregut Malformation Type III with Pulmonary Sequestration Diagnosed in a Newborn: A Case Report

Communicating bronchopulmonary foregut malformation (CBPFM) is a communication between the respiratory and gastrointestinal tracts that can be difficult to differentiate from pulmonary sequestration or H-type tracheoesophageal fistula (TEF) because of the similarities in clinical features. A female neonate born at full term had been experiencing respiratory difficulty during feeding from the third day of life. The esophagography performed to rule out H-type TEF revealed that the esophageal bronchus directly communicated with the left lower lobe (LLL) of the lung. Lobectomy of the LLL, fistulectomy of the esophagobronchial fistula, and primary repair of the esophagus were performed. Finally, CBPFM type III with pulmonary sequestration was confirmed on the basis of the postoperative histopathological finding. We report the first newborn case of CBPFM type III with pulmonary sequestration in Korea.

Pulmonary inhalation-perfusion scintigraphy in the evaluation of bronchoscopic treatment of bronchopleural fistula / Cintilografia pulmonar inalatória na avaliação do tratamento broncoscópico de fístula broncopleural

Abstract Objective: To evaluate the use of pulmonary inhalation-perfusion scintigraphy as an alternative method of investigation and follow-up in patients with bronchopleural fistula (BPF). Materials and Methods: Nine patients with BPFs were treated through the off-label use of a transcatheter atrial septal defect occluder, placed endoscopically, and were followed with pulmonary inhalation-perfusion scintigraphy, involving inhalation, via a nebulizer, of 900-1300 MBq (25-35 mCi) of technetium-99m-labeled diethylenetriaminepentaacetic acid and single-photon emission computed tomography with a dual-head gamma camera. Results: In two cases, there was a residual air leak that was not identified by bronchoscopy or the methylene blue test but was detected only by pulmonary inhalation-perfusion scintigraphy. Those results correlated with the evolution of the patients, both of whom showed late signs of air leak, which confirmed the scintigraphy findings. In the patients with complete resolution of symptoms and fistula closure seen on bronchoscopy, the scintigraphy was completely negative. In cases of failure to close the BPF, the scintigraphy confirmed the persistence of the air leak. In two patients, scintigraphy was the only method to show residual BPF, the fistula no longer being seen on bronchoscopy. Conclusion: We found pulmonary inhalation-perfusion scintigraphy to be a useful tool for identifying a residual BPF, as well as being an alternative method of investigating BPFs and of monitoring the affected patients.

Resumo Objetivo: Avaliar a cintilografia por inalação-perfusão pulmonar como método alternativo de investigação e acompanhamento em pacientes com fístula broncopleural (FBP). Materiais e Métodos: Nove pacientes com FBPs foram tratados de forma endoscópica com o uso off label de um oclusor transcateter de defeito do septo interatrial e foram seguidos com cintilografia de inalação-perfusão pulmonar usando tomografia computadorizada por emissão de fóton único com câmera de cintilação de duas cabeças e inalação com 900-1300 MBq (25-35 mCi) de ácido dietilenotriaminopentacético marcado com tecnécio-99m, inserido num nebulizador. Resultados: Broncoscopia e teste de azul de metileno não foram capazes de detectar dois casos de vazamento residual, detectados apenas por cintilografia por inalação-perfusão pulmonar. Esses resultados foram correlacionados com a evolução desses pacientes que tardiamente apresentaram sinais de vazamento de ar confirmando os achados da cintilografia. Pacientes com resolução completa dos sintomas e com aspecto broncoscópico do fechamento da fístula apresentaram cintilografia negativa completa. Em casos de falha no fechamento da FBP, a cintilografia por inalação-perfusão confirmou a persistência da fuga de ar. Em dois pacientes, a cintilografia foi o único método a mostrar FBP residual, apesar da ausência da fístula por avaliação broncoscópica. Conclusão: Neste estudo, a cintilografia de inalação-perfusão pulmonar mostrou ser um instrumento útil para identificar FBP residual e como método alternativo de investigação e seguimento de pacientes com FBPs.

Fístula biliopleurobronquial: reporte de un caso / Bronchobiliary fistula: Report of a case

La fístula biliopleurobronquial (FBB) es una comunicación anormal entre la vía biliar y el árbol bronquial. Es una condición infrecuente, generalmente secundaria a un proceso infeccioso local o a un evento traumático. La bilioptisis es patognomónica. Presentamos el caso de una mujer de 37 años con historia de cirrosis biliar secundaria, en lista para trasplante hepático, con múltiples episodios de colangitis previos y usuaria de derivación biliar externa, quien curso con bilioptisis y mediante gammagrafía HIDA con SPECT se confirmó fistula biliopleurobronquial. Éste caso se resolvió con derivación percutánea de la vía biliar

Bronchobiliary fistula (BBF) is an abnormal communication between the biliary tract and the bronchial tree. Is an infrequent condition, usually secondary to a local infectious process or a traumatic event. Bilioptisis is pathognomonic. We present the case of a 37 year old woman with secondary biliary cirrhosis, in list for liver transplantation, with several episodes of cholangitis and carrier of external biliary diverivation, who presented bilioptisis and HIDA scintigraphy with SPECT confirmed BBF. This case was resolved with percutaneous derivation of the biliary tract

Fístula colobrônquica por adenocarcinoma de cólon: relato de caso / Colobronchial fistula due to colon adenocarcinoma: case report

Fístula colobrônquica é uma complicação rara de doença do trato gastrintestinal. Geralmente manifesta com sintomatologia respiratória inespecífica, o que dificulta o diagnóstico. Pode ser a primeira manifestação da doença abdominal, refletindo quadro avançado e, portanto, de difícil abordagem. Relatamos o caso de uma paciente do sexo feminino, 72 anos, que apresentou fístula colobrônquica por adenocarcinoma de cólon no ângulo esplênico, manifestada por tosse crônica.(AU)

The colobronchial fistula is a rare complication of gastrointestinal tract disease. It is usually manifested with nonspecific respiratory symptomatology, which makes diagnosis difficult. It may be the first manifestation of abdominal disease, reflecting advanced disease and therefore being difficult to approach. We report a case of a female patient, 72 years old, who presented with colobronchial fistula due to colon adenocarcinoma in the splenic angle, manifested by chronic cough.(AU)

Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage Due to Empyema / 대한구급학회지

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Abordaje toraco-abdominal de la fístula broncobiliar / Thoraco-abdominal approach in bronchobiliary fistula

La fístula broncobiliar es una entidad poco usual en nuestro medio y poco descrita en la literatura científica. Se caracteriza por una comunicación anómala entre el árbol bronquial y la vía biliar, y se asocia a la presencia de bilis en el esputo (bilioptisis). Según su etiología, puede ser secundaria a la obstrucción distal de la vía biliar por patología benigna, maligna, infecciosa o iatrogénica. Se presenta el caso de un paciente de 33 años, que cursó con una fístula broncobiliar secundaria a la derivación de la vía biliar percutánea por una lesión estenótica del confluente biliar, en quien ­por medio de un abordaje torácico y abdominal­ se practicó una lobectomía inferior por videotoracoscopia (Video-Assisted Thoracoscopy Surgery, VATS) y hepatectomía con reconstrucción de la vía biliar por laparotomía. Teniendo en cuenta lo inusual del caso, con pocos reportes en la literatura, se concluye la dificultad para establecer la posible etiología de las estenosis de la vía biliar en un paciente joven, sin poderse descartar la enfermedad maligna. Al hacer el diagnóstico, se debe tratar y corregir la causa; la cirugía sigue siendo el pilar del tratamiento y, con el advenimiento de la cirugía mínimamente invasiva, se puede hacer un manejo combinado para aprovechar los beneficios de la técnica, como se hizo en este caso

Bronchobiliary fistula is a rare entity in our environment and it is poorly described in the scientific literature. It is characterized by an abnormal communication between the bronchial tree and the biliary tract, and is associated with the presence of bile in the sputum (bilioptysis). According to its etiology, it may be secondary to a distal obstruction of the bile duct due to a benign, malignant, infectious, or iatrogenic pathology. We present the case of a 33-year-old patient who had a bronchobiliary fistula secondary to a percutaneous biliary tract bypass due to a stenotic lesion of the biliary confluent in whom an inferior lobectomy by video-assisted thoracoscopy surgery (VATS) was performed with hepatectomy with biliary tract reconstruction by laparotomy, a combined thoracic and abdominal approach. Given the low incidence of this type of cases and the scarce literature reports, our conclusion is that it is difficult to define the possible etiology of the bile duct stenosis in young patients, and that a malignant pathology cannot be ruled out. Once the diagnosis is established, the cause should be treated. Surgery remains the mainstay of treatment, and with the advent of minimally invasive surgery a combined type of management can be performed so as to take advantage of the benefits of this technology

Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage Due to Empyema / 대한중환자의학회지

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Hepatobronchial Fistula and Lung Abscess after Transarterial Chemoembolization / 대한소화기학회지

Transarterial chemoembolization (TACE) is a common treatment modality to locally manage hepatocellular carcinoma. Liver abscess and bile duct injury are common complications of TACE. However, hepatobronchial fistula is a rare complication. Herein, we report a case of lung abscess due to hepatobronchial fistula after TACE. A 67-year-old man, who had underwent TACE 6 months ago, presented cough and bile-colored sputum. He was diagnosed with lung abscess and hepatobronchial fistula. We performed endoscopic retrograde cholangiopancreatography; however, there was no improvement in his symptoms. Thereafter, partial hepatectomy and repair of fistula were successively conducted.

Diagnosis and treatment of hepatic cystic echinococcosis complicated with Brocho-biliary fistula / 中华肝胆外科杂志

Broncho-biliary fistula (BBF) is an abnormal channel for pathological bile drainage,which has very low incidence,high mortality and complex pathology.It is difficult to diagnose and cure this disease.Currently,the diagnosis of hepatic cystic echinococcosis complicated with brocho-biliary fistula is even more difficult.The sensitivity of magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) is relatively high.The main treatment is surgery.Surgical treatment could be divided into the abdominal,thoracic and thoracoabdominal surgery based on the location of the incision.The common surgical approach is the simple abdominal incision,which is associated with rapid recovery,minimal trauma and the capability of handling the abdomen and chest lesions.

Communicating Tubular Esophageal Duplication Combined with Bronchoesophageal Fistula

Esophageal duplication (ED) is rarely diagnosed in adults and is usually asymptomatic. Especially, ED that is connected to the esophagus through a tubular communication and combined with bronchoesophageal fistula (BEF) is extremely rare and has never been reported in the English literature. This condition is very difficult to diagnose. Although some combinations of several modalities, such as upper gastrointestinal endoscopy, esophagography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, can be used for the diagnosis, the results might be inconclusive. Here, we report on a patient with communicating tubular ED that was incidentally diagnosed on the basis of endoscopy and esophagography during the postoperational evaluation of BEF.

The bronchoscopic features of endobronchial tuberculosis induced by lymphatic fistula and the efficacy of interventional treatment / 实用医学杂志

Objective To explore the bronchoscopic features of endobronchial tuberculosis induced by lymphatic fistula and the efficacy of interventional treatment. Methods The data on 31 patients with endobronchial tuberculosis induced by lymphatic fistula who had received bronchoscopic diagnosis and treatment in our hospital during the period of January 2010 to June 2013 were reviewed. The bronchoscopic features , along with the frequency of interventional therapies and duration of the therapies , were retrospectively analyzed; and the efficacy of the therapies and the related complications were assessed. Rusults The endoscopic appearance showed: granuloma (19.4%), necrosis (51.6%), granuloma with necrosis (25.8%), and fistulous opening (3.2%). Dark gray matter or carbon deposition inside the lesions was the characteristics of endobronchial tuberculosis induced by lymphatic fistula. There were 76 orificium fistulae in 31 patients , mostly in the right side. The median frequency of treatment was five in patients with single orificium fistulae and the median treatment duration was 65 days; whereas the median frequency of treatment was nine in patients with multiple fistulae and the median treatment duration was 108 days. There were significant differences between the two groups (P < 0.05 for both comparisons). The effectiveness rate of treatment was 98.7%. The therapy-related complication was of a small amount of bleeding, with a rate of 2.1%. Conlusions Endobronchial tuberculosis induced by lymphatic fistula shows certain characteristics under bronchoscopic examination. Bronchoscopic clamping combined with infusions with antituberculosis agents is a safe, simple, effective therapeutic method.

Polymicrobial Purulent Pericarditis Probably caused by a Broncho-Lymph Node-Pericardial Fistula in a Patient with Tuberculous Lymphadenitis

Purulent pericarditis is a rare condition with a high mortality rate. We report a case of purulent pericarditis subsequently caused by Candida parapsilosis, Peptostreptococcus asaccharolyticus, Streptococcus anginosus, Staphylococcus aureus, Prevotella oralis, and Mycobacterium tuberculosis in a previously healthy 17-year-old boy with mediastinal tuberculous lymphadenitis. The probable route of infection was a bronchomediastinal lymph node-pericardial fistula. The patient improved with antibiotic, antifungal, and antituberculous medication in addition to pericardiectomy.

Diagnóstico e tratamento da fístula bronquiobiliar / Review article management of bronchobiliary fistula

Fístula bronquiobiliar (FBB) é uma afecção rara, de alta morbidade e mortalidade, decorrente da comunicação anormal entre a árvore brônquica e a via biliar, sendo a bilioptise um sinal clínico patognomônico. Normalmente está associada a doenças hepatobiliares, mas principalmente ao trauma e complicações de cirurgias hepatobiliares. Devido à gravidade e à complexidade, associadas à baixa incidência, seu manejo é desafiador, não havendo um consenso na literatura. Este trabalho identifica os métodos diagnósticos e terapêuticos mais utilizados, e propõe um fluxograma do manejo da FBB com intuito de auxiliar a conduta de novos casos.

Bronchobiliary fistula is a rare clinical finding, with a high morbidity and mortality rate, characterized by abnormal communication between the biliary tract and the bronchial tree, having bilioptysis as a pathognomonic sign. It is usually associated to hepatobiliary diseases, but mostly related to trauma and as a complication of hepatobiliary surgery. Due to the low incidence, complexity and gravity, its management is a challenge, and little consensus on its diagnosis and treatment exists. We identified the most used diagnostic and therapeutic procedures, and propose a flowchart that could assist in the management of news cases.

Modified method for bronchial suture by Ramirez Gama compared to separate stitches suture: experimental study / Sutura de brônquios pelo método de Ramirez Gama modificado comparada à sutura com pontos separados: estudo experimental

OBJECTIVE: To experimentally compare two classic techniques described for manual suture of the bronchial stump. METHODS: We used organs of pigs, with isolated trachea and lungs, preserved by refrigeration. We dissected 30 bronchi, which were divided into three groups of ten bronchi each, of 3mm, 5mm, and 7mm, respectively. In each, we performed the suture with simple, separated, extramucosal stitches in five other bronchi, and the technique proposed by Ramirez and modified by Santos et al in the other five. Once the sutures were finished, the anastomoses were tested using compressed air ventilation, applying an endotracheal pressure of 20mmHg. RESULTS: the Ramirez Gama suture was more effective in the bronchi of 3, 5 and 7 mm, and there was no air leak even after subjecting them to a tracheal pressure of 20mmHg. The simple interrupted sutures were less effective, with extravasation in six of the 15 tested bronchi, especially in the angles of the sutures. These figures were not significant (p = 0.08). CONCLUSION: manual sutures of the bronchial stumps were more effective when the modified Ramirez Gama suture was used in the caliber bronchi arms when tested with increased endotracheal pressure. .

OBJETIVO: comparar experimentalmente duas técnicas clássicas descritas para a sutura manual do coto brônquico. MÉTODOS: foram empregadas vísceras de suínos com a traqueia e os pulmões isolados, conservados por refrigeração. Foram dissecados 30 brônquios, divididos em três grupos de dez brônquios cada, com 3mm, 5mm e 7mm, respectivamente. Em cada um dos grupos foi realizada a sutura com pontos simples separados extramucosos em cinco brônquios e nos outros cinco, foi empregada a técnica proposta por Ramirez Gama e modificada por Santos et al. Terminadas as suturas, as anastomoses foram testadas com ventilação empregando ar comprimido, submetidas a uma pressão endotraqueal de 20mmHg. RESULTADOS: os pontos de Ramirez Gama foram mais efetivos em brônquios de 3, 5 e 7 mm, e não houve extravasamento de ar mesmo após submetê-los a uma pressão endotraqueal de 20mmHg. Os pontos simples separados foram menos efetivos, havendo extravasamento em seis dos 15 brônquios testados, principalmente nos ângulos das suturas. Estes números não foram significativos (p=0,08). . CONCLUSÃO: as suturas manuais dos cotos brônquicos foram mais efetivas quando o ponto de Ramirez Gama modificado foi utilizado nos brônquios de pequeno calibre quando testados com aumento da pressão endotraqueal. .

A Case of Bronchonodal Fistula by Endobronchial Tuberculosis / 계명의대학술지

The Bronchial fistula is caused by infection, malignancy, trauma, inflammatory disease and foreign body. The bronchonodal fistula by endobronchial tuberculois is very rare complication. The authors present a 70-year-old man presented with hoarseness and sore throat. This patient diagnosed with endobronchial tuberculosis, which was complicated by bronchonodal fistula by sputum acid fast bacilli stain, bronchoscopy, and chest computed tomography. The patient was treated with antituberculosis therapy for 1 year, and follow up bronchoscopy and radiologic study showed regression of bronchonodal fistula.

Use of the Free Flap for Large Defect with Bronchopleural Fistula: Case Report

Bronchopleural fistula is an unnatural communication between the bronchial tree and pleural space. Closure of the bronchial stump using various muscular flaps has been previously reported. There have been few reports on treatment of large defects with bronchopleural fistula accompanied by surrounding muscle injury. We report on our experience with two patients suffering from large defect with bronchopleural fistula, who were treated with free flaps. No recurrence of bronchopleural fistula was observed during follow-up.

A unilateral large bronchopleural fistula caused by rupture of bulla with coexisting bilateral giant bullae: A case report

A patient with a large bronchopleural fistula presents several intraoperative challenges for the anesthesiologist, particularly if bullae coexist bilaterally. Ideally, a double lumen tube is inserted while the patient is conscious or breathing spontaneously under general anesthesia to prevent possible tension pneumothorax in the contralateral lung due to positive-pressure ventilation and the possibility of inadequate ventilation due to an air leak from the fistula. However, we inserted a single lumen tube instead of a double lumen tube, because this patient had multiple giant bullae bilaterally and the contralateral lung tissue was almost completely compressed and destroyed. We report the use of a single lumen tube under volatile general anesthesia with synchronized intermittent mandatory ventilation with small tidal volume. In addition, we used permissive hypercapnia to further minimize barotraumas. Due to permissive hypercapnia, there were no cardiovascular consequences.

Surgical therapy for bronchobiliary fistula due to hepatic cystic echinococcosis / 中华普通外科杂志

Objective To explore the diagnosis and treatment efficacy of bronchobiliary fistula due to hepatic cystic echinococcosis.Methods A retrospective evaluation of 39 patients with BBF was performed during 1992 to 2012.We divided the 39 patients into group A treated before 2001 and group B after 2002.A retrospective analysis was made.Results There were three deaths among the 39 BBF patients due to hepatic hydatid disease.The cause of death was septic shock due to severe infection.There were no statistical differences in the basic factors,age (t =0.84,P =0.554),gender (P =1.0),and sputum volume (t =0.98,P =0.703),hydatid diameter (t =1.11,P =0.406),operation time,chest infection (P =1.0),mortality (P =0.235) between the two groups (P ＞ 0.05).While postoperative length of stay(t =7.64,P =0.000),postoperative complications of residual cavity (P =0.001),length of tube drainage(t =6.747,P =0.01),recurrence of bronchial fistula (P =0.022),pleural dissemination (P =0.018),reoperation rate (P =0.049) were all in favour of group B (P ＜ 0.05).Conclusions Surgery is the choice of therapy for BBF due to hepatic hydatid disease,and one-stage procedure is expected to achieve the best outcomes.

Semiología broncoscópica. Descripción de dos nuevos signos / Bronchoscopic signs: Description of two new signs

Se describen dos nuevos signos endoscópicos que podrán resultar de utilidad para mejorar el rendimiento diagnóstico de la broncoscopia. Un ensayo semiológico sobre circunstancias anatómicas y funcionales particulares, que declaran la existencia de una afección cercana, pero fuera del alcance de observación del broncoscopista. Estos dos signos son el “signo de la burbuja” y el “signo del agujero negro”. El signo de la burbuja se observa cuando no hay flujo del aire en un subsegmento bronquial que conduce a una masa pulmonar periférica. Esto se manifiesta por la ausencia de burbujas móviles cuando se inyecta una solución salina en el subsegmento bronquial. El signo del agujero negro consiste en una penumbra circular observada en el extremo de un bronquio que se comunica con una cavidad. Se describen las formas de presentación e interpretación de estos signos y también se ofrece una explicación acerca de su fisiopatología.

The paper describes two new endoscopic signs which can be useful in the use of diagnostic bronchoscopy. This is an essay on particular anatomic and functional circumstances suggesting the presence of a pathology which cannot be seen by the bronchoscopist. These two signs are the Bubble Sign and the Black Hole Sign. The Bubble Sign is observed when the airflow is absent in a subsegmental bronchus leading to a peripheral pulmonary mass. This can be shown by the lack of mobile bubbles when a subsegmental bronchus is flooded with saline solution. The Black Hole Sign consists in the circular penumbra observed at the end of a bronchus which communicates with a cavity. The paper describes the presentation and interpretation of these signs and offers an explanation about their physiopathology.