Abstract
BACKGROUND: Postoperative loculated pleural collections can mimic empyema and present diagnostic challenges, especially when transthoracic access is limited due to altered anatomy. CASE PRESENTATION: We present the case of a 67-year-old male who developed a pleural collection six months after right superior bilobectomy for central squamous cell lung carcinoma. Due to mediastinal shift and limited transthoracic access, EBUS was used under LMA ventilation to access the loculated pleural pocket adjacent to the right paratracheal region. This unconventional but anatomically justified approach allowed safe sampling when standard ultrasound-guided thoracentesis was not feasible, demonstrating a minimally invasive diagnostic alternative in complex postoperative thoracic anatomies. A total of 15 cc pleural fluid was aspirated, which grew Streptococcus pneumoniae. The patient responded well to antibiotics and remains asymptomatic at 9 months. CONCLUSIONS: This case highlights a novel application of EBUS in post-surgical thoracic anatomy, offering a minimally invasive alternative when conventional aspiration routes are inaccessible.