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Giant cervical herniation of an apical pulmonary bulla
J THoRAc CARDIOVASC SURG 1987;93:141-7
Brief communications Giant cervical herniation of an apical pulmonary bulla Solomon Victor, ER.C.S., F.R.C.P., S. Muthurajan, M.S., T. G. Sekhar, Ramya Gopinath, Bharathi Dhala, M.D., Vasundhra Devi, M.D., A. Gajaraj, M.D., and M. S. Venkataraman, M.S., F.A.C.S., Madras, India From the Departments of Cardiothoracic Surgery and General Surgery, Government General Hospital, Madras, and the Department of Radiology, Apollo Hospital, Madras. India.
A 60-year-old woman had a giant air cyst in the right side of the neck, which arose from the apex of the right lung. We are unable to find a similar case report in literature.
Air-containing lesions in the cervical region usually are due to laryngocele, pharyngocele, rupture of piriform sinus,' infection caused by gas-forming organisms, subcutaneous emphysema,' or congenital or acquired herniation of the lung.' To our knowledge giant cervical herniation of an apical bulla of the lung has not been reported previously. Case report. A 60-year-old woman had a progressive painless lump in the right side of the neck of about 15 years' duration. She had an occasional cough. There were no episodes of asthma or wheeze. She had never smoked. Clinical examination revealed a frail, elderly woman in whom the only abnormal clinical finding was a giant hyperresonant mass in the right supraclavicular region, which showed a cough impulse (Figs. 1 and 2). No breath sounds or adventitious sounds were heard. The mass could not be reduced, and it became tense with the Yalsalva maneuver. Routine examination of urine and blood showed no abnormalities. Roentgenogram of the chest and neck (Fig. 3) showed a thin-walled, unilocular, air-containing cyst in the right supraclavicular region with a retroclavicular para tracheal extension into the apex of the right lung. The rest of the lung fields were emphysematous. Computed tomographic scan confirmed the unilocular nature of the cyst and its intrathoracic origin (Fig. 4). At operation in May 1984, a supraclavicular incision was made on the right side. The cyst wall was thin and glistening
Address for reprints: Professor Solomon Victor, 15, East Street, Kilpauk Garden Colony, Madras 600 010, India.
Fig. 1. Front view of patient with giant air cyst of neck.
Fig. 2. Side view of patient with giant air cyst of neck. with scanty serous fluid. There was no communication with the larynx or pharynx. The intrathoracic extension was found behind the clavicle, anterior to the scalenus muscle and anterior and lateral to the trachea. An alveolar air leak, 1 by 1 em in diameter, in the apex of the right lung, fed the cyst. This area was sutured. The cyst was obliterated by plicating the walls. The woman made an uneventful recovery and remained asymptomatic in June 1985.
Discussion. The radiologic and operative findings in this case establish a diagnosis of air-containing solitary 141
The Journal 01 Thoracic and Cardiovascular Surgery
1 4 2 Brief communications
Fig. 3. Roentgenogram showing air cyst in neck.
have been incriminated in the pathogenesis.' Weakness of parietal pleura, Sibson's fascia, and neck muscles has also been considered as a causative factor.' In infants the hernia has regressed after the growth of the child.' Other hernias, hydrocele,' and cleft lip," and cri du chat syndrome? have been reported in association with cervical herniation of the lung. In the present case, one might consider the possibility of a bulla arising from a preexisting cervical hernia of the lung. However, the intrathoracic location of the lower pole of the bulla and the site of air leak argue against this possibility. Emphysematous bullae may be asymptomatic or lead to bleeding, infection, or pneumothorax." The bullae may become tense and compress the rest of the lung," Herniation of a bulla into the neck has not been reported previously.
2 3
4 5 6 Fig. 4. Computed tomographic scan shows unilocular cyst with intrathoracic extension.
7
8
emphysematous bulla arising from the upper lobe of the right lung. It is likely that the bulla developed inside the chest and later protruded into the neck through the suprapleural membrane (Sibson's fascia). Dense apical adhesions may have prevented an intrathoracic extension. It is of interest that lung can herniate into the neck.' Cervical herniation of the lung is characterized by crepitus on palpation and breath sounds, rales, and rhonchi on auscultation.' The mass can often be reduced.? These features were absent in the present case. Cervical herniation accounts for 25% of hernias of the lung." They are commoner in male than female patients and in patients above 45 years and below 15 years of age.' These hernias may be congenital or acquired. 2 Persistent cough, playing wind instruments, glass blowing, lifting heavy weights, and straining at stools or labor
REFERENCES Grunebaum M, Gricom T: Protrusion of the lung apex through Sibson's fascia in infancy. Thorax 33:290-294, 1978 Reinhart HA, Hermel MB: Herniation of the lung in the cervical region. Radiology 57:204-207, 1951 Van Wegel N: Cervical hernia of the lung. JAMA 142:804-805, 1950 Jones JG: Cervical herniation of lung. J Pediatr 76:122225, 1970 Bronsther B, Coryllos E, Epstein B, Abrams MW: Lung hernias in children. J Pediatr Surg 3:544-550, 1968 Plazzo WL, Garret T A: Cervical hernia of the lung. Radiology 56:575-576, 1951 Cunningham D, Peters ER: Cervical hernia of the lung associated with cri du chat syndrome. Am J Dis Child 118:769-771,1969 Grimes OF, Farber SM: Air cysts of the lung. Surg Gynecol Obstet 113:720-728, 1961
Colon bypass from the oral cavity Ebrahim Arnod Vanker, F.R.C.S., Durban, Republic of South Africa From the Department of Cardia- Thoracic Surgery, University of Natal and Wentworth Hospital, Durban, Republic of South Africa.
A young man had had caustic burns of the pharynx, larynx, and stomacb 4 years previously. Total gastrectomy bad been performed, and nutrition was maintained through a
esopha~
Address for reprints: E. A. Vanker, F.R.C.S., Department of CardioThoracic Surgery, Wentworth Hospital, Private Bag Jacobs 4026, Durban, Natal, Republic of South Africa.
Brief communications Giant cervical herniation of an apical pulmonary bulla Solomon Victor, ER.C.S., F.R.C.P., S. Muthurajan, M.S., T. G. Sekhar, Ramya Gopinath, Bharathi Dhala, M.D., Vasundhra Devi, M.D., A. Gajaraj, M.D., and M. S. Venkataraman, M.S., F.A.C.S., Madras, India From the Departments of Cardiothoracic Surgery and General Surgery, Government General Hospital, Madras, and the Department of Radiology, Apollo Hospital, Madras. India.
A 60-year-old woman had a giant air cyst in the right side of the neck, which arose from the apex of the right lung. We are unable to find a similar case report in literature.
Air-containing lesions in the cervical region usually are due to laryngocele, pharyngocele, rupture of piriform sinus,' infection caused by gas-forming organisms, subcutaneous emphysema,' or congenital or acquired herniation of the lung.' To our knowledge giant cervical herniation of an apical bulla of the lung has not been reported previously. Case report. A 60-year-old woman had a progressive painless lump in the right side of the neck of about 15 years' duration. She had an occasional cough. There were no episodes of asthma or wheeze. She had never smoked. Clinical examination revealed a frail, elderly woman in whom the only abnormal clinical finding was a giant hyperresonant mass in the right supraclavicular region, which showed a cough impulse (Figs. 1 and 2). No breath sounds or adventitious sounds were heard. The mass could not be reduced, and it became tense with the Yalsalva maneuver. Routine examination of urine and blood showed no abnormalities. Roentgenogram of the chest and neck (Fig. 3) showed a thin-walled, unilocular, air-containing cyst in the right supraclavicular region with a retroclavicular para tracheal extension into the apex of the right lung. The rest of the lung fields were emphysematous. Computed tomographic scan confirmed the unilocular nature of the cyst and its intrathoracic origin (Fig. 4). At operation in May 1984, a supraclavicular incision was made on the right side. The cyst wall was thin and glistening
Address for reprints: Professor Solomon Victor, 15, East Street, Kilpauk Garden Colony, Madras 600 010, India.
Fig. 1. Front view of patient with giant air cyst of neck.
Fig. 2. Side view of patient with giant air cyst of neck. with scanty serous fluid. There was no communication with the larynx or pharynx. The intrathoracic extension was found behind the clavicle, anterior to the scalenus muscle and anterior and lateral to the trachea. An alveolar air leak, 1 by 1 em in diameter, in the apex of the right lung, fed the cyst. This area was sutured. The cyst was obliterated by plicating the walls. The woman made an uneventful recovery and remained asymptomatic in June 1985.
Discussion. The radiologic and operative findings in this case establish a diagnosis of air-containing solitary 141
The Journal 01 Thoracic and Cardiovascular Surgery
1 4 2 Brief communications
Fig. 3. Roentgenogram showing air cyst in neck.
have been incriminated in the pathogenesis.' Weakness of parietal pleura, Sibson's fascia, and neck muscles has also been considered as a causative factor.' In infants the hernia has regressed after the growth of the child.' Other hernias, hydrocele,' and cleft lip," and cri du chat syndrome? have been reported in association with cervical herniation of the lung. In the present case, one might consider the possibility of a bulla arising from a preexisting cervical hernia of the lung. However, the intrathoracic location of the lower pole of the bulla and the site of air leak argue against this possibility. Emphysematous bullae may be asymptomatic or lead to bleeding, infection, or pneumothorax." The bullae may become tense and compress the rest of the lung," Herniation of a bulla into the neck has not been reported previously.
2 3
4 5 6 Fig. 4. Computed tomographic scan shows unilocular cyst with intrathoracic extension.
7
8
emphysematous bulla arising from the upper lobe of the right lung. It is likely that the bulla developed inside the chest and later protruded into the neck through the suprapleural membrane (Sibson's fascia). Dense apical adhesions may have prevented an intrathoracic extension. It is of interest that lung can herniate into the neck.' Cervical herniation of the lung is characterized by crepitus on palpation and breath sounds, rales, and rhonchi on auscultation.' The mass can often be reduced.? These features were absent in the present case. Cervical herniation accounts for 25% of hernias of the lung." They are commoner in male than female patients and in patients above 45 years and below 15 years of age.' These hernias may be congenital or acquired. 2 Persistent cough, playing wind instruments, glass blowing, lifting heavy weights, and straining at stools or labor
REFERENCES Grunebaum M, Gricom T: Protrusion of the lung apex through Sibson's fascia in infancy. Thorax 33:290-294, 1978 Reinhart HA, Hermel MB: Herniation of the lung in the cervical region. Radiology 57:204-207, 1951 Van Wegel N: Cervical hernia of the lung. JAMA 142:804-805, 1950 Jones JG: Cervical herniation of lung. J Pediatr 76:122225, 1970 Bronsther B, Coryllos E, Epstein B, Abrams MW: Lung hernias in children. J Pediatr Surg 3:544-550, 1968 Plazzo WL, Garret T A: Cervical hernia of the lung. Radiology 56:575-576, 1951 Cunningham D, Peters ER: Cervical hernia of the lung associated with cri du chat syndrome. Am J Dis Child 118:769-771,1969 Grimes OF, Farber SM: Air cysts of the lung. Surg Gynecol Obstet 113:720-728, 1961
Colon bypass from the oral cavity Ebrahim Arnod Vanker, F.R.C.S., Durban, Republic of South Africa From the Department of Cardia- Thoracic Surgery, University of Natal and Wentworth Hospital, Durban, Republic of South Africa.
A young man had had caustic burns of the pharynx, larynx, and stomacb 4 years previously. Total gastrectomy bad been performed, and nutrition was maintained through a
esopha~
Address for reprints: E. A. Vanker, F.R.C.S., Department of CardioThoracic Surgery, Wentworth Hospital, Private Bag Jacobs 4026, Durban, Natal, Republic of South Africa.