- Email: [email protected]
Cervical pulmonary herniation due to blunt chest trauma
Legal Medicine 13 (2011) 301–303
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Cervical pulmonary herniation due to blunt chest trauma } a,⇑, Judit Halász b, Boglárka Marcsa a, Dávid Biczó a, Ágnes Nemeskéri c Klára Töro a
}i út 93, Hungary Department of Forensic and Insurance Medicine, Semmelweis University, Hungary, 1091 Budapest, Üllo }i út 93, Hungary 2nd Department of Pathology, Semmelweis University, 1091 Hungary, Budapest, Üllo c }i út 93, Hungary Department of Human Morphology and Developmental Biology, Semmelweis University, 1091 Budapest, Üllo b
a r t i c l e
i n f o
Article history: Received 25 August 2011 Received in revised form 7 September 2011 Accepted 7 September 2011
Keywords: Chest trauma Lung herniation Traffic accident Post-mortem investigation
a b s t r a c t Traumatic lung herniation through the superior thoracic aperture rarely occurs. In this case report we present a motor vehicle accident of a 40 year old male victim with cervical lung herniation. After an enormous blunt trauma to the chest, the disrupted and lacerated lung tissue left the thoracic cavity and was pushed into the laryngeal and oral cavity. Extrathoracic post-traumatic lung herniation through the thoracic inlet and connective tissue spaces of the neck into the oral cavity is a unique complication of blunt trauma to the chest, and the post-mortem medico-legal investigations may collect more information about this phenomenon. Ó 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Lung hernias are classified by location and etiology. They occur through thoracic wall defect (chest wall type), through the thoracic inlet into the neck region (cervical type), and into abdominal cavity (diaphragmatic type). Etiologically, they are either congenital or acquired by trauma, chest wall neoplasms or infection [1]. Herniation of the lung through a traumatically induced thoracic wall defect is a rare occurrence. The first case [2] was reported in 1933, however, during this century motor vehicle accidents have replaced penetrating thoracic trauma as the most common etiologic agent of traumatic lung herniation [3]. In this report we present a case of cervical lung herniation after an enormous blunt chest trauma. Disrupted and lacerated lung tissue left the thoracic cavity and was pushed into the laryngeal and oral (changed the word order) cavity. 2. Case report A 40-year-old man was working as a yard master while he suffered an accident while directing a truck’ shunting. He was run over by the back side of the truck, and he died immediately after the accident at the scene before the ambulance arrived (Fig. 1a–c). 2.1. Autopsy findings During the external examination, severe damages were observed on the lower extremities and lung tissue mass was found ⇑ Corresponding author. Tel.: +36 12157300. } ). E-mail address: [email protected] (K. Töro 1344-6223/$ - see front matter Ó 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2011.09.002
in the oral cavity and in front of the lips (Fig. 2). The internal examination demonstrated herniation of the right lung through the right superior thoracic aperture with tracheobronchial disruption. The anatomical continuity of the superior mediastinum and the connective tissue spaces of the neck demonstrates the topography of the route of herniating lung (Fig. 3). The extreme sudden pressure exerted on the victim’s chest wall disrupted the cervical parietal pleura and the medial weaker part of fascial suprapleural membrane (costovertebral fascia). This forced the lung tissue into the uppermost part of the superior mediastinum behind the subclavian vessels then further proximally into the lateral pharyngeal space. Along the path of least resistance, the lung proceeded into the potential space above the mylohyoid muscle, broke through the mucosal floor of the oral cavity and appeared between the lips. The victim suffered other injuries like severe bruises to his right torso, multiple lacerations of the bilateral and multiple rib fractures, fracture of the sternum, vertebral fractures, lung contusion, liver and splenic laceration, and right haemothorax. 2.2. Histology Histology samples were embedded in paraffin, cut into approximately 5-lm-thick sections and stained with hematoxylin and eosin (HE). Extensive hemorrhage within the lung parenchyma and haemosiderin-laden macrophages in the hemorrhagic area can be seen (Fig. 4 a and b). The final cause of death in the presented case was determined as traumatic shock due to enormously big blunt trauma to the chest. A blood alcohol concentration test and toxicology yielded negative results.
302
} et al. / Legal Medicine 13 (2011) 301–303 K. Töro
Fig. 1. Position of the victim at the scene (a, b). Traumatic lesion of the left lower limb (c).
Fig. 2. Lung tissue material situated in front of the face.
Fig. 3. Supraclavicular herniation demonstrated during the forensic autopsy.
Fig. 4. (a) Extensive hemorrhage in the lung parenchyma (HE, 100X). (b) Haemosiderin-laden macrophages in the hemorrhagic area (HE, 600X).
} et al. / Legal Medicine 13 (2011) 301–303 K. Töro
3. Discussion We reported a rare case of cervical lung herniation via a motor vehicle accident. Lung contusion and tracheobronchial disruption by blunt trauma have been frequently detected in road traffic accidents [4–7]. Lung hernia, a protrusion of a part of the lung through a defect in the thoracic cage [1] may be covered with intact pleural sac or the disrupted parietal pleura. The incidence of non-fatal traumatic lung herniation is difficult to estimate as it is likely that many remain occult because of a low index of suspicion, subtle physical findings, and lack of symptoms [3]. Until recently, fewer than 300 traumatic lung herniations have been recorded [1,8]. The thoracic cage has inherent weakness anteriorly and posteriorly where there is only a single layer of intercostal muscle [1]. The anterior thoracic wall adjacent to the sternum is the site of predilection for both spontaneous and traumatic lung herniation presumably because the anterior thorax lacks the muscular support afforded the posterior thoracic wall by the trapezius, latissimus dorsi, and rhomboid muscles [3]. Lung herniations are classified as different types: (a) Cervical herniation of the apex of the lung into the soft tissues of the neck is the least common type. In adults the etiology is either post -traumatic or secondary to chronic respiratory disease, or due to an inherited connective tissue disorder such as Ehlers–Danlos syndrome (EDS) [9]. Aoki et al. [10] described a bilateral cervical lung hernia in the supraclavicular fossa resulting from severe chronic obstructive pulmonary disease. The most proximal levels of the cervical hernia sac were reported to extend up to the level of thyroid cartilage [11] and up to the submental area [12]. In children, the condition appears to arise spontaneously as a result of a congenital defect in the costovertebral fascia (fascial suprapleural membrane or Sibson’s fascia) [13]. (b) About two-thirds of the lung hernias occur through the chest wall, mostly anteriorly. Anterior lung herniation may occur during shoulder harness trauma in a motor vehicle crash, as a thoracic manifestation of the seatbelt syndrome [8]. (c) Transdiaphragmatic lung hernia is rare, likely because intra-abdominal pressure is higher than intrathoracic pressure [1]. Lung herniation is a rare complication of blunt chest trauma. Herniation may occur through a congenital chest wall defect or through an acquired abnormality when intrathoracic pressure increases with trauma [14]. Acquired chest wall defects may result from multiple rib fractures or from sternoclavicular or costochondral dislocations [15]. The antero-lateral chest wall is more susceptible to traumatic lung herniation because of the minimal soft tissue support (intercostal muscles) compared to the posterior chest wall. Traumatic lung hernias most frequently occur medial to the beginning of the costal cartilage where the external intercostal muscles are missing and internal intercostal muscles are thin. Lung may also herniate through the intercostal space as a result of preceding thoracic operation or video thoracoscopy [16]. Usually post-traumatic lung herniation is visualized on chest radiographs as well-circumscribed air radiolucencies above the
303
thoracic inlet. However, tangential views may be necessary in some patients to demonstrate the herniation [3]. On chest radiographs, immediate post-traumatic lung hernias can be initially obscured by chest wall hematomas [17]. CT scanning confirms the extent and anatomy of the lung injury [18]. Pulmonary contusions are the most common pulmonary injuries after blunt chest trauma, and they result from damage to interstitial or alveolar tissue with subsequent blood pooling and edema [14]. Pulmonary laceration occurs from the effect of shearing forces over the lung parenchyma. Skeletal injuries, fracture of the sternum, serial rib fractures, and fracture of vertebrae are indicators of high-impact blunt chest trauma. Traumatic lung herniation through the superior thoracic aperture and the connective tissue spaces of the neck into the oral cavity is a unique complication of blunt trauma to the chest. Post-mortem medico-legal investigations may collect more information about this phenomenon. The mechanism of this fatal truck accident suggests that special training for staff regarding the shunting and movement of trucks in busy city environments is important to improve injury prevention. References [1] Getzoff A, Shaves S, Carter Y, Foy H. Traumatic lung herniation. AJR 1999;172:1032. [2] Goodman HI. Hernia of lung. J Thorac Surg 1933;2:368–79. [3] Allen GS, Fischer RP. Traumatic lung herniation. Ann Thorac Surg 1977;63:1456–8. [4] Date K, Kato S, Yoshihara M, Kondo K, Beppu K, Nagata Y. Two cases of tracheobronchial disruption due to blunt trauma. Kyobu Geka 1997;50:201–4. [5] Michalska A, Jurczyk AP, Machala W, Szram S, Berent J. Pulmonary contusion and acute respiratory distress syndrome (ARDS) as complications of blunt chest trauma. Arch Med Sadowej Kryminol 2009;59:148–54. [6] Filosso PL, Oliaro A, Donati G, Rena O. Post-traumatic hernia of the lung. Eur J Cardiothorac Surg 2000;19:360. [7] Lang-Lazdunski L, Bonnet PM, Pons F, Brinquin L, Jancovici R. Traumatic extrathoracic lung herniation. Ann Thorac Urg 2002;74:927–9. [8] May AK, Chan B, Daniel TM, Young JS. Anterior lung herniation: another aspect of the seatbelt syndrome. J Trauma 1995;38:587–9. [9] Evans AS, Nassif RG, Ah-See KW. Spontaneous apical lung herniation presenting as a neck lump in a patient with Ehlers–Danlos syndrome. Surgeon 2005;3:49–51. [10] Aoki T, Takagi H, Ando T, Iida K, Ito M. Cervical lung hernia in a case of severe chronic asthma and bronchitis. Nihon Kyobu Shikkan Gakkai Zasshi 1991;29:632–7. [11] Lightwood RG, Cleland WP. Cervical lung hernia. Thorax 1974;29:349–51. [12] Jheon S, Lee EB, Cho JY, Chang BH, Lee J, Kim KT. Thoracoscopic repair of cervical lung hernia. J Thorac Cardiovasc Surg 2002;124:1030–1. [13] Thompson JS. Cervical herniation of the lung. Report of a case and review of the literature. Pediatr Radiol 1976;4:190–2. [14] Sangster GP, Gonzalez-Beicos A, Carbo AI, Heldmann MG, Ibrahim H, Carrascosa P, et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol 2007;14:297–310. [15] Francois B, Desachy A, Cornu E, Ostyn E, Niquet L, Vignon P. Traumatic pulmonary hernia: surgical versus conservative management. J Trauma 1998;44:217–9. [16] Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg 2002;74:1963–6. [17] Fiane AE, Nordstrand K. Intercostal pulmonary hernia after blunt thoracic injury. Eur J Surg 1993;159:379–81. [18] Bhalla M, Leitman BS, Forcade C, Stern E, Naidich DP, McCauley DI. Lung hernia: radiographic features. AJR 1990;154:51–3.
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Cervical pulmonary herniation due to blunt chest trauma } a,⇑, Judit Halász b, Boglárka Marcsa a, Dávid Biczó a, Ágnes Nemeskéri c Klára Töro a
}i út 93, Hungary Department of Forensic and Insurance Medicine, Semmelweis University, Hungary, 1091 Budapest, Üllo }i út 93, Hungary 2nd Department of Pathology, Semmelweis University, 1091 Hungary, Budapest, Üllo c }i út 93, Hungary Department of Human Morphology and Developmental Biology, Semmelweis University, 1091 Budapest, Üllo b
a r t i c l e
i n f o
Article history: Received 25 August 2011 Received in revised form 7 September 2011 Accepted 7 September 2011
Keywords: Chest trauma Lung herniation Traffic accident Post-mortem investigation
a b s t r a c t Traumatic lung herniation through the superior thoracic aperture rarely occurs. In this case report we present a motor vehicle accident of a 40 year old male victim with cervical lung herniation. After an enormous blunt trauma to the chest, the disrupted and lacerated lung tissue left the thoracic cavity and was pushed into the laryngeal and oral cavity. Extrathoracic post-traumatic lung herniation through the thoracic inlet and connective tissue spaces of the neck into the oral cavity is a unique complication of blunt trauma to the chest, and the post-mortem medico-legal investigations may collect more information about this phenomenon. Ó 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Lung hernias are classified by location and etiology. They occur through thoracic wall defect (chest wall type), through the thoracic inlet into the neck region (cervical type), and into abdominal cavity (diaphragmatic type). Etiologically, they are either congenital or acquired by trauma, chest wall neoplasms or infection [1]. Herniation of the lung through a traumatically induced thoracic wall defect is a rare occurrence. The first case [2] was reported in 1933, however, during this century motor vehicle accidents have replaced penetrating thoracic trauma as the most common etiologic agent of traumatic lung herniation [3]. In this report we present a case of cervical lung herniation after an enormous blunt chest trauma. Disrupted and lacerated lung tissue left the thoracic cavity and was pushed into the laryngeal and oral (changed the word order) cavity. 2. Case report A 40-year-old man was working as a yard master while he suffered an accident while directing a truck’ shunting. He was run over by the back side of the truck, and he died immediately after the accident at the scene before the ambulance arrived (Fig. 1a–c). 2.1. Autopsy findings During the external examination, severe damages were observed on the lower extremities and lung tissue mass was found ⇑ Corresponding author. Tel.: +36 12157300. } ). E-mail address: [email protected] (K. Töro 1344-6223/$ - see front matter Ó 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2011.09.002
in the oral cavity and in front of the lips (Fig. 2). The internal examination demonstrated herniation of the right lung through the right superior thoracic aperture with tracheobronchial disruption. The anatomical continuity of the superior mediastinum and the connective tissue spaces of the neck demonstrates the topography of the route of herniating lung (Fig. 3). The extreme sudden pressure exerted on the victim’s chest wall disrupted the cervical parietal pleura and the medial weaker part of fascial suprapleural membrane (costovertebral fascia). This forced the lung tissue into the uppermost part of the superior mediastinum behind the subclavian vessels then further proximally into the lateral pharyngeal space. Along the path of least resistance, the lung proceeded into the potential space above the mylohyoid muscle, broke through the mucosal floor of the oral cavity and appeared between the lips. The victim suffered other injuries like severe bruises to his right torso, multiple lacerations of the bilateral and multiple rib fractures, fracture of the sternum, vertebral fractures, lung contusion, liver and splenic laceration, and right haemothorax. 2.2. Histology Histology samples were embedded in paraffin, cut into approximately 5-lm-thick sections and stained with hematoxylin and eosin (HE). Extensive hemorrhage within the lung parenchyma and haemosiderin-laden macrophages in the hemorrhagic area can be seen (Fig. 4 a and b). The final cause of death in the presented case was determined as traumatic shock due to enormously big blunt trauma to the chest. A blood alcohol concentration test and toxicology yielded negative results.
302
} et al. / Legal Medicine 13 (2011) 301–303 K. Töro
Fig. 1. Position of the victim at the scene (a, b). Traumatic lesion of the left lower limb (c).
Fig. 2. Lung tissue material situated in front of the face.
Fig. 3. Supraclavicular herniation demonstrated during the forensic autopsy.
Fig. 4. (a) Extensive hemorrhage in the lung parenchyma (HE, 100X). (b) Haemosiderin-laden macrophages in the hemorrhagic area (HE, 600X).
} et al. / Legal Medicine 13 (2011) 301–303 K. Töro
3. Discussion We reported a rare case of cervical lung herniation via a motor vehicle accident. Lung contusion and tracheobronchial disruption by blunt trauma have been frequently detected in road traffic accidents [4–7]. Lung hernia, a protrusion of a part of the lung through a defect in the thoracic cage [1] may be covered with intact pleural sac or the disrupted parietal pleura. The incidence of non-fatal traumatic lung herniation is difficult to estimate as it is likely that many remain occult because of a low index of suspicion, subtle physical findings, and lack of symptoms [3]. Until recently, fewer than 300 traumatic lung herniations have been recorded [1,8]. The thoracic cage has inherent weakness anteriorly and posteriorly where there is only a single layer of intercostal muscle [1]. The anterior thoracic wall adjacent to the sternum is the site of predilection for both spontaneous and traumatic lung herniation presumably because the anterior thorax lacks the muscular support afforded the posterior thoracic wall by the trapezius, latissimus dorsi, and rhomboid muscles [3]. Lung herniations are classified as different types: (a) Cervical herniation of the apex of the lung into the soft tissues of the neck is the least common type. In adults the etiology is either post -traumatic or secondary to chronic respiratory disease, or due to an inherited connective tissue disorder such as Ehlers–Danlos syndrome (EDS) [9]. Aoki et al. [10] described a bilateral cervical lung hernia in the supraclavicular fossa resulting from severe chronic obstructive pulmonary disease. The most proximal levels of the cervical hernia sac were reported to extend up to the level of thyroid cartilage [11] and up to the submental area [12]. In children, the condition appears to arise spontaneously as a result of a congenital defect in the costovertebral fascia (fascial suprapleural membrane or Sibson’s fascia) [13]. (b) About two-thirds of the lung hernias occur through the chest wall, mostly anteriorly. Anterior lung herniation may occur during shoulder harness trauma in a motor vehicle crash, as a thoracic manifestation of the seatbelt syndrome [8]. (c) Transdiaphragmatic lung hernia is rare, likely because intra-abdominal pressure is higher than intrathoracic pressure [1]. Lung herniation is a rare complication of blunt chest trauma. Herniation may occur through a congenital chest wall defect or through an acquired abnormality when intrathoracic pressure increases with trauma [14]. Acquired chest wall defects may result from multiple rib fractures or from sternoclavicular or costochondral dislocations [15]. The antero-lateral chest wall is more susceptible to traumatic lung herniation because of the minimal soft tissue support (intercostal muscles) compared to the posterior chest wall. Traumatic lung hernias most frequently occur medial to the beginning of the costal cartilage where the external intercostal muscles are missing and internal intercostal muscles are thin. Lung may also herniate through the intercostal space as a result of preceding thoracic operation or video thoracoscopy [16]. Usually post-traumatic lung herniation is visualized on chest radiographs as well-circumscribed air radiolucencies above the
303
thoracic inlet. However, tangential views may be necessary in some patients to demonstrate the herniation [3]. On chest radiographs, immediate post-traumatic lung hernias can be initially obscured by chest wall hematomas [17]. CT scanning confirms the extent and anatomy of the lung injury [18]. Pulmonary contusions are the most common pulmonary injuries after blunt chest trauma, and they result from damage to interstitial or alveolar tissue with subsequent blood pooling and edema [14]. Pulmonary laceration occurs from the effect of shearing forces over the lung parenchyma. Skeletal injuries, fracture of the sternum, serial rib fractures, and fracture of vertebrae are indicators of high-impact blunt chest trauma. Traumatic lung herniation through the superior thoracic aperture and the connective tissue spaces of the neck into the oral cavity is a unique complication of blunt trauma to the chest. Post-mortem medico-legal investigations may collect more information about this phenomenon. The mechanism of this fatal truck accident suggests that special training for staff regarding the shunting and movement of trucks in busy city environments is important to improve injury prevention. References [1] Getzoff A, Shaves S, Carter Y, Foy H. Traumatic lung herniation. AJR 1999;172:1032. [2] Goodman HI. Hernia of lung. J Thorac Surg 1933;2:368–79. [3] Allen GS, Fischer RP. Traumatic lung herniation. Ann Thorac Surg 1977;63:1456–8. [4] Date K, Kato S, Yoshihara M, Kondo K, Beppu K, Nagata Y. Two cases of tracheobronchial disruption due to blunt trauma. Kyobu Geka 1997;50:201–4. [5] Michalska A, Jurczyk AP, Machala W, Szram S, Berent J. Pulmonary contusion and acute respiratory distress syndrome (ARDS) as complications of blunt chest trauma. Arch Med Sadowej Kryminol 2009;59:148–54. [6] Filosso PL, Oliaro A, Donati G, Rena O. Post-traumatic hernia of the lung. Eur J Cardiothorac Surg 2000;19:360. [7] Lang-Lazdunski L, Bonnet PM, Pons F, Brinquin L, Jancovici R. Traumatic extrathoracic lung herniation. Ann Thorac Urg 2002;74:927–9. [8] May AK, Chan B, Daniel TM, Young JS. Anterior lung herniation: another aspect of the seatbelt syndrome. J Trauma 1995;38:587–9. [9] Evans AS, Nassif RG, Ah-See KW. Spontaneous apical lung herniation presenting as a neck lump in a patient with Ehlers–Danlos syndrome. Surgeon 2005;3:49–51. [10] Aoki T, Takagi H, Ando T, Iida K, Ito M. Cervical lung hernia in a case of severe chronic asthma and bronchitis. Nihon Kyobu Shikkan Gakkai Zasshi 1991;29:632–7. [11] Lightwood RG, Cleland WP. Cervical lung hernia. Thorax 1974;29:349–51. [12] Jheon S, Lee EB, Cho JY, Chang BH, Lee J, Kim KT. Thoracoscopic repair of cervical lung hernia. J Thorac Cardiovasc Surg 2002;124:1030–1. [13] Thompson JS. Cervical herniation of the lung. Report of a case and review of the literature. Pediatr Radiol 1976;4:190–2. [14] Sangster GP, Gonzalez-Beicos A, Carbo AI, Heldmann MG, Ibrahim H, Carrascosa P, et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol 2007;14:297–310. [15] Francois B, Desachy A, Cornu E, Ostyn E, Niquet L, Vignon P. Traumatic pulmonary hernia: surgical versus conservative management. J Trauma 1998;44:217–9. [16] Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg 2002;74:1963–6. [17] Fiane AE, Nordstrand K. Intercostal pulmonary hernia after blunt thoracic injury. Eur J Surg 1993;159:379–81. [18] Bhalla M, Leitman BS, Forcade C, Stern E, Naidich DP, McCauley DI. Lung hernia: radiographic features. AJR 1990;154:51–3.