To my understanding, the aorta and esophagus are outside the pleural cavity. How then would perforation of these structures cause pleural effusion, which we know they often do?
Any inflammatory process close to pleural may stimulate pleural macrophages to produce inflammatory cytokines as TNF inducing pleural effusion Even systemic inflammatory reaction as in sepsis may induce pleural effusion by the same mechanism The same happens with subphrenic abscess or acute pancreatitis
Some may use the term extra-pleural space, the definition with examples of processes that may affect this space. On imaging, many would call these processes pleural-based or the extra-pleural fluid pleural effusions. While these descriptors may be anatomically incorrect, the distinction is often not clinically relevant.
Article Multidetector CT for Evaluation of the Extrapleural Space
Esophageal perforation is probably more similar to descending thoracic aortic aneurysm rupture (or traumatic rupture) than dissection. In perforated esophagus or ruptured aorta, the extraluminal fluid needs somewhere to go. As the linked article describes above, maybe these or extrapleural rather than pleural or maybe the insult caused a tear or communication with the adjacent pleura. The processes and where ruptured content would communicate are different for the ascending aorta and the upper to mid esophagus (mediastinal).
Pleural effusions associated with dissection may be an inflammatory mediated process (as Marcel C Machado excellently explains) and third spacing of the false lumen. If it results in pleural or extrapleural blood, it may be related to tiny microruptures.
Article Clinical Significance of Pleural Effusion in Acute Aortic Dissection
the effusion my happen 2ry to the inflammatory process that will be induced by the extravasation of the blood into a space that is usually not suppose to be in contact either with the blood coming from perforated aorta or with the saliva/feed coming from perforated esophagus.
Aortic aneurysm rupture initially is produced in mediastinum. Ongoing hemorrhage will lead to the rupture of hematoma
in peural cavity.
Any inflammatory process near the pleura may stimulate macrophages to produce inflammatory cytokines.
Rupture may occur into the pleura and so the effusion is direct contamination and secondary inflammatory response OR if contained rupture inside the mediastinal pleura then the effusion is purely reactive
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