In contrast to the two prior decades, empyema in children has become a rare disease during the past 10 years. Thirty-two children with empyema from all causes were treated at The Children's Memorial Hospital in Chicago in the 11 years between 1970 and 1982. Twenty cases followed postinfectious pneumonia, most commonly due to Staphylococcus aureus. The remaining patients had either an esophageal leak or a pleural infection following an intrathoracic operation. Fourteen of our patients were managed with a "mini-thoracotomy," which allowed accurate drainage of purulent material, débridement of fibrinous exudate, and rapid expansion of the lung with prompt relief from fever and toxicity. In our hands, this procedure provided results which were superior to those obtained with simple closed chest tube drainage. In addition, during this period of time, ultrasound examination of the chest has provided a rapid, accurate technique for the early detection and localization of fluid accumulations within the pleural cavity. Pre-drainage thoracentesis can be accurately guided by ultrasonic imaging.