Hernia of the lung: case report and literature review

Cervical lung herniation of the azygous lobe: a case report and literature review

PURPOSE

To report an adult case of cervical lung herniation involving the azygous lobe and to review the literature.

METHODS

A trauma patient was incidentally found to have a cervical lung herniation involving the azygous lobe. We reviewed the literature on cervical lung herniation, described techniques used to diagnose and evaluate cervical lung herniations and summarized management options.

RESULTS

Cervical lung herniation results in a defect in Sibson's fascia allowing the apical lung to protrude above the thoracic inlet. In the adult population, these are commonly seen after trauma or surgical intervention, but congenital forms have also been described in the pediatric population. Apical herniation of the lung can cause symptoms due to mass effect on the esophagus or trachea. We report an adult case of cervical lung herniation involving the azygous lobe.

CONCLUSION

Cervical lung herniation is a relatively rare entity compared to lung herniation through the rib cage. Knowledge of this entity is essential to properly evaluate trauma patients and to diagnose patients who have symptoms of cough, dysphagia or a bulging neck mass.

Spontaneous pulmonary herniation in post-polio syndrome

Pulmonary hernias are typically a result of trauma, thoracic operations, or congenital defects. Spontaneous lung hernias without a prior overt injury are notably rare. The presence of spontaneous lung hernias has not been reported in post-polio syndrome. Post-polio syndrome is a late sequela of poliomyelitis that usually presents 30-40 years after the initial illness with new presentations of progressive muscle weakness, abnormal muscle fatigue, muscle atrophy, and myalgia. This case report describes the presentation and imaging of a post-polio patient with an atraumatic, spontaneous lung hernia. A discussion on pulmonary hernias, diagnostic imaging, and management is also included.

Case Report: Spontaneous lung intercostal hernia series and literature review

Spontaneous lung intercostal hernia (SLIH) is a rare condition potentially carrying severe morbidity. About 120 cases have been described so far, with an apparently increasing number of reports in recent years. The main presenting findings are chest pain and bulging, with ecchymosis in the affected area, hemoptysis, respiratory distress, and signs of infection or incarceration being described as well. The gold standard treatment has not been established, and conservative management has been advocated as first-line treatment for asymptomatic patients. Here, we report a case series of five patients, and surgical repair was deemed necessary for four of them either at first evaluation or after failure of conservative management. One patient remains under surveillance and conservative management. We believe that SLIH surgical repair should be considered as first-line treatment for fit patients, due to the uncertainty of its mid- and long-term impact and described pejorative trend/defect enlargement. A proposed algorithm for SLIH management is also presented.

A 64-Year-Old Man with Traumatic Right Middle Lobe Lung Herniation Successfully Managed Conservatively

Patient: Male, 64-year-old

Final Diagnosis: Right lung hernia • trauma

Symptoms: Chest pain • shortness of breath

Medication: —

Clinical Procedure: Chest tube • conservative management

Specialty: Thoracic Surgery • Radiology • Trauma Surgery

Intercostal lung herniation secondary to thoracotomy: a case report

Intercostal lung herniation is defined as a protrusion of the lung parenchyma through a defect in the intercostal muscles between adjacent ribs. The authors report a case of intercostal pulmonary hernia in a 45-year-old male patient, with smoking habit (30 packs-year), presented to the emergency department with dyspnea. He had the history of pulmonary emphysema complicated with a total right pneumothorax in 2015 treated by mini-thoracotomy with bullectomy and pleural abrasion. In 2019, he was admitted to hospital for left chest pain. The computed tomography (CT) scan of the chest revealed a bilateral emphysema with intercostal lung hernia through the fourth intercostal space the patient underwent, a left thoracotomy with repair of the intercostal muscle defect. He was discharged from hospital free of complications.

Case of intercostal lung hernia with hemosputum that developed after thoracoscopic lobectomy

Intercostal lung hernia is defined as a protrusion of the lung tissue through a chest wall defect. It is an uncommon condition after a lobectomy, and most cases are asymptomatic. We herein report a case of intercostal lung hernia after a thoracoscopic right upper lobectomy in a patient whose chief complaint was hemosputum. Elevated intrathoracic pressure is a major risk factor for intercostal lung hernia. In this patient, obesity and bronchial asthma were considered the causes of this disease. Three reports on intercostal lung hernia after thoracoscopic lobectomy were previously published. In three of the four lung hernia cases (including our own), right upper lobectomy had been performed, and the middle lobe was herniated. We consider right upper lobectomy to be an anatomical risk factor.

Thoracic herniation secondary to pleural effusion

We present the case of a 61-year-old gentleman with history of stage IV esophageal cancer presented to the emergency department with the complaints of dyspnea on exertion and cough of 1-month duration. Patient had undergone resection of distal esophagus 4 years' prior this admission. Chest radiograph revealed a large right pleural effusion and, a computed tomography scan of the chest revealed a portion of the effusion herniating between the ribs in the right hemithorax. Thoracentesis was performed with improvement in patient's dyspnea and overall condition. Patient was doing better and asymptomatic on his 3-month follow-up. Inadequate closure after surgical procedure can lead to presentation of a lung herniation. This can appear immediately after or many years later. Video-assisted thoracoscopy has been attributed to post-operative presentation of thoracic hernias when compared to more extensive operative procedures.

Cervical lung herniation complicating a case of acute asphyxial asthma in a child

The abrupt onset of respiratory failure secondary to asthma, known as acute asphyxial asthma (AAA) in adults, is uncommonly reported in children. Here, we report a case of a child with the acute onset of respiratory failure consistent with AAA complicated by the finding of a neck mass during resuscitation. This 11-year-old boy with a history of asthma initially presented in respiratory failure with altered mental status after the complaint of difficulty in breathing minutes before collapsing at home. Initially, his respiratory failure was thought to be secondary to status asthmaticus, and treatment was initiated accordingly. However, a neck mass noted during the resuscitation was cause for concern, and other etiologies for his respiratory failure were considered, including an airway obstructing neck mass. After pediatric surgery and anesthesia consultation for intubation and possible tracheostomy placement, general anesthesia was induced in the operating room with an inhaled anesthetic, with prompt resolution of the bronchspasm and decompression of the neck mass. Review of the imaging and clinical course ultimately yielded a diagnosis of cervical lung herniation as the etiology of his neck mass. We report this case of AAA and cervical lung herniation and a review of the literature of these 2 uncommon phenomena in children.

Primary and Prosthetic Repair of Acquired Chest Wall Hernias: A 20-Year Experience

BACKGROUND

Chest wall herniation has been described after thoracotomy, trauma, and violent coughing episodes. Few studies have examined risk factors associated with chest wall herniation or predictors of complications after surgical repair.

METHODS

A divisional database identified all patients who underwent chest wall herniorrhaphy between 1992 and 2011. Data were collected on patient age, sex, body mass index (BMI), cause and location of hernia, comorbidities, duration and technique of herniorrhaphy, postoperative complications, and hospital length of stay. Risk factors for chest wall herniation were then examined, and primary repair was compared with prosthetic repair for differences in postoperative morbidity.

RESULTS

Twenty-seven consecutive patients underwent chest wall herniorrhaphy. Hernias most commonly occurred on the right side, in the fifth intercostal space, contained lung, and were chronic in nature. Pain was the presenting symptom in all but 4 patients. The most frequently observed comorbidities were obesity, chronic obstructive pulmonary disease (COPD), oral steroid use, and diabetes mellitus. Primary repair was performed in 18 patients and mesh repair in 9 patients, with a median operative time of 116 minutes. Excluding the 4 acute hernias repaired during the same admission as the initial thoracotomy, postoperative complications occurred in 22% of patients who underwent prosthetic repair and 42% of patients who underwent primary repair (p=0.4). Median hospital stay did not differ between herniorrhaphy techniques.

CONCLUSIONS

Previous thoracotomy, obesity, COPD, steroid use, and diabetes mellitus are common in patients in whom chest wall hernias develop. Prosthetic herniorrhaphy is not associated with an increased risk of postoperative complications relative to primary repair.

Intercostal lung herniation--the role of imaging

Extrathoracic lung hernias can be congenital or acquired. Acquired hernias may be classified by etiology into traumatic, spontaneous, and pathologic. We present a case of a 40-year-old male with a history of bronchial asthma and a blunt chest trauma who presented complaining of sharp chest pain of acute onset that began after five consecutive days of vigorous coughing. Upon physical examination a well-demarcated deformity overlying the third intercostal space of the left upper anterior hemithorax was revealed. Thoracic CT scan showed that a portion of the anterior bronchopulmonary segment of the left upper lobe had herniated through a chest wall defect. The role of imaging, especially chest computed tomography with multiplanar image reconstructions and maximum (MIP) and minimum intensity projection (MinIP) reformats can clearly confirm the presence of the herniated lung, the hernial sac, the hernial orifice in the chest wall, and exclude possible complications such as lung tissue strangulation.

Intermittent swelling in the chest; a case of spontaneous intermittent lung herniation

Herniation of the lung is uncommon and occurs due to protrusion of the lung beyond the confines of the thoracic cavity through an abnormal opening in the chest wall. Any condition associated with raised intrathoracic pressure or that which weakens the thoracic wall may result in lung herniation. We present a case of spontaneous lung herniation which was managed successfully by minimally invasive thoracic surgery.

Spontaneous Transient Lateral Thoracic Lung Herniation Resulting in Systemic Inflammatory Response Syndrome (SIRS) and Subsequent Contralateral Lung Injury

Lung herniation is a relatively rare clinical entity that is most commonly either congenital or acquired traumatically. We describe a case of spontaneous lung herniation secondary to acute cough in an obese male smoker complicated by contralateral acute lung injury and systemic inflammatory response syndrome (SIRS). Mechanisms of lung herniation, classification, diagnosis, and management will be discussed.

[Spontaneous thoracic hernias--report of two cases, surgically treated]

The authors present two cases of atraumatic (spontaneous) thoracic lung hernias, which are extreme rarities in the international literature, too. Risk factors and clinical pictures discussed and operative treatments are demonstrated. The spontaneous thoracic (intercostal) hernias were provoked by intractable cough caused by chronic obstructive pulmonary disease (COPD) in both cases. Multi-slice spiral CT (MSCT) scan as well as the secondary 3D 'volume rendering' (VRT) reconstructions unequivocally suggested this rare condition. Provided with the exact diagnosis, the surgical correction of the thoracic wall resulted in full recovery of the two patients. Finally, the authors briefly discuss data of thoracic hernias published in the Hungarian and the international literature. They conclude that the awareness of this extremely rare condition is important due to the high prevalence of COPD as a risk factor. Diagnostic imaging demonstrated can provide significant help in the correct diagnosis of similar cases.

Extrathoracic herniation of a lung bulla through a tube thoracostomy site

We report a case of lung bulla herniation occurring two years after a tube thoracostomy application due to pneumothorax. A new bulla can develop or a pre-existing bulla can herniate through a weak part of thoracic wall, a tube thoracostomy site as in our case. Diagnostic and radiological features of this uncommon case are described.

Pathological Pulmonary Hernia in a Patient With Metastatic Breast Cancer

Introduction: Pathological pulmonary hernia is a rare clinical entity which can be caused by malignancies. Clinical Picture: A 72-year-old female presented with a painful bulge in the left 4th intercostal space. Chest radiography and computed tomography demonstrated a left pulmonary hernia, pleural effusion and destruction of ribs. Treatment: The hernia sac was excised and a part of the chest wall was resected with reconstruction of residual defect. Outcome: The patient died 2 years after the treatment. Conclusions: A multidisciplinary approach involving various medical specialists may offer patients with pathological pulmonary hernia remarkable palliation and better quality of life. Key words: Palliative care, Surgical flaps, Surgical mesh

Spontaneous apical lung herniation presenting as a neck lump in a patient with Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a heritable group of disorders of connective tissue characterised by skin hyperlaxity, joint hypermobility and tissue fragility. We report on a 49-year-old man with EDS who presented with spontaneous swelling at the root of the right neck during coughing. The size and site of the lesion led to diagnostic uncertainty. Subsequent computerised tomography (CT) scanning during a Valsalva manoeuvre demonstrated a large apical lung hernia arising through the costo-vertebral fascia into the root of the neck. No previous reports have documented spontaneous apical lung herniation in patients with EDS. This case serves to remind all practitioners dealing with the head and neck to remember the apical lung as a potential source of pathology in the neck.

Herniation of the lung after video-assisted thoracic surgery

We report a case of lung herniation occurring following video-assisted thoracic surgery. Although lung hernias are rare, the widespread application of video-assisted thoracic surgery to patients at risk for lung hernia will likely result in more reports in the future. Consequently, pulmonologists and thoracic surgeons must be aware of this condition, risk factors for development, and potential methods of prevention in order to minimize the occurrence of this complication.

Atraumatic lung hernia

Lung hernia is a distinctly rare event, regardless of its location and cause. Most lung hernias are acquired traumatic thoracic hernias. All previously reported cases of acquired spontaneous lung hernia involve some aspect of trauma, most commonly caused by vigorous coughing with a subsequent rib fracture. We report a case of totally atraumatic, acquired spontaneous lung hernia.

Lung herniation secondary to minimally invasive direct coronary artery bypass grafting

Lung herniation after thoracotomy is rare. We report a 66-year-old man who presented with this complication after undergoing attempted minimally invasive direct coronary artery bypass grafting. The defect was repaired with a composite of Marlex mesh and methyl methacrylate.

Hernia of the lung repaired by VATS: a case report

Hernia of the lung is an uncommon clinical entity. The majority of reported hernias are acquired traumatic thoracic hernias. A case of an acquired spontaneous hernia occurring through an old anterior thoracotomy scar is presented. We believe pathogenesis of this hernia was the result of increased intrathoracic pressure secondary to tracheobronchomegaly and anterior-posterior collapse of the trachea during expiration. The hernia was successfully repaired by a video-assisted thoracic surgical (VATS) technique using prolene mesh and a hernia stapler similar to the technique used in repair of an inguinal hernia.