Background: patients with parapneumonic effusion and empyema must be managed probably to avoid surgery and decortication, the use of medical thoracoscope and instillation of streptokinase intra pleural through intercostal tube consider a modality of dealing with that medical situation. Aim of study: it was to compare the therapeutic yield of medical thoracoscope and intrapleural fibrinolysis by streptokinase in complicated parapneumonic effusion and empyema. Patients and methods: this study was conducted at Endoscopy Unit in Chest Department, Al- Hussin Hospitals, Al-Azhar University and Damanhur Chest Hospital in the period between May 2016 and May 2019. This study included 50 patients with complicated parapneumonic effusion and empyema. They were divided into 2 groups: Group A (25 patients): managed by medical thoracoscopy, Group B (25 patients): managed by intercostal tube drainage (ICT) plus intrapleural instillation of streptokinase as fibrinolytic agent. Results: twenty three (92%) patients improved and 2(8%) failed in group A (thoracoscopic group) and 16(64%) patients improved and 9(36%) not completely improved in group B (Streptokinase group) with significant statistical difference. Conclusion and Conclusion: we conclude that medical thoracoscope is very effective, successful and safe in management of such cases. Also, the use of streptokinase as fibrinolytic is safe and effective but not with the same degree of medical thoracoscope. Patients with parapneumonic effusion and empyema must be managed probably to avoid the risk of surgery and other complications.