A Surprising Complication of Tube Thoracostomy: A Case of Persistent Hiccups

Dear Editor, Tube thoracostomy involves placing a drain into the pleural space to allow unidirectional drainage. Common indications include pneumothorax, pleural effusion, hemothorax, empyema, and chylothorax. It is also used intraoperatively to monitor air leaks, and for pleurodesis in recurrent effusions or pneumothorax. Its earliest use was by Hippocrates in the fifth century BC following empyema.[1] Special care is needed in patients with intrathoracic adhesions or diaphragmatic elevation. While chest tube insertion is generally straightforward, obesity and pleural adhesions may complicate the procedure.[2] Complication rates range from 9% to 21%,[3] and may be early (e.g. pain, bleeding, organ injury, subcutaneous emphysema, malposition) or late (e.g. prolonged air leak, infection, empyema, hernia, scarring, fistula). Nerve injury may occur at any stage. To minimize risks, appropriate imaging, correct intercostal access, strict sterilization, and close clinical-radiological follow-up are essential.[2] To date, there have been no reported cases of hiccups as a complication of tube thoracostomy in the literature. In this case, we aimed to report a 75-year-old female patient, who developed hiccups immediately after the tube thoracostomy procedure and experienced complete resolution of the hiccups upon removal of the drain. A 75-year-old female patient with a medical history significant for hypertension and chronic obstructive pulmonary disease (COPD), but no other comorbidities was hospitalized at an outside facility due to rib fractures and hemothorax following a fall, where the left-sided tube thoracostomy was performed. After discharge, she presented to our facility for follow-up. A thorax computed tomography revealed a left-sided loculated effusion, warranting hospitalization. A thoracic computed tomography (CT) scan was reviewed, and thoracentesis was performed from several locations. Upon obtaining hemorrhagic fluid from the seventh intercostal space, a 24 French tube thoracostomy was inserted through the same space. A post-procedure chest X-ray confirmed that the drain was in the seventh intercostal space, extending through the costophrenic angle and overlying the diaphragm [Figure 1]. No complications such as bleeding, parenchymal injury, air leak, or malposition were observed during the procedure. The patient developed persistent hiccups immediately after drain placement, accompanied by 100 cc/day hemorrhagic drainage for 2 days. As the drainage ceased due to hematoma formation, the tube was removed on day three, leading to the immediate hiccup resolution. Post-removal imaging showed persistent loculated effusion, but surgery was not planned due to the patient’s age and condition. She was discharged with follow-up, and no hiccup recurrence occurred. Written informed consent was obtained for academic use of her medical data.Figure 1: In the post-procedural direct radiograph, the drain is visible at the tip of the green arrowTube thoracostomy carries various complications, requiring preventive strategies and effective management. Collop et al.[4] identified malposition and obstruction as the most common issues, with Huber et al.[5] reporting an 11.2% malposition rate. Misplacement may necessitate repeat procedures and cause pain. Over-advancement can irritate nerves and pleura, while under-advancement may lead to subcutaneous emphysema.[6] Other complications, include chylothorax, winged scapula, Horner’s syndrome, diaphragmatic paralysis, and rarely, persistent hiccups from phrenic nerve irritation.[2] Hiccups are sudden, involuntary contractions of the diaphragm, usually self-limiting. Persistent hiccups last 2–30 days, while chronic ones persist beyond a month. In chronic cases, phrenic nerve block, radiofrequency ablation, or surgical intervention may be considered.[7] Persistent hiccups during sleep may suggest organic pathology.[8] Phrenic nerve irritation can result from infections, tumours, trauma, or foreign bodies. Various medical and interventional treatments exist. Arsanious et al.[9] reported successful resolution of hiccups after sequential bilateral phrenic nerve blocks following esophageal stent placement. In one study, continuous local anaesthetic infusion near the phrenic nerve relieved hiccups, which recurred after cessation but resolved with a second 24-hour infusion.[7] Kang et al.[10] reported temporary relief with phrenic nerve block and full resolution after ultrasound-guided pulsed radiofrequency ablation. In our case, hiccups developed as a complication of tube thoracostomy and resolved immediately after drain removal. In conclusion, hiccups, although seemingly a simple symptom, can be associated with various underlying causes and may require invasive interventions for treatment. Tube thoracostomy can also induce hiccups as a complication and this possibility should be kept in mind. The purpose of presenting this case was to share with you a complication of tube thoracostomy that, to the best of our knowledge, has not previously been reported in the literature. Author contributions H.E.Y: Conception, materials, critical review; S.E.A Writer, literature review, design; H.E.C: Supervision, data collection, analysis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.