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Intercostal lung hernia in a 7-year-old boy
Intercostal Lung Hernia in a 7-Year-Old Boy By Anindya Chattopadhyay, M. YogaNagendhar, Bhanu Prakash, and Vijayakumar Karnataka, India
The authors report a case of a lateral chest wall lung hernia, which was presumably congenital. Lung herniations are extremely rare, and congenital herniation of the lung through an apparently intact thoracic cage has not yet been reported. The hernia was repaired by the interposition of a polypropylene mesh. The literature of this rare condition is briefly reviewed.
J Pediatr Surg 39:1432-1433. © 2004 Elsevier Inc. All rights reserved.
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vical, thoracic, or diaphragmatic.5 These groups are stratified further according to the presumed etiology as congenital or acquired; the latter group contains the traumatic, “spontaneous,” and the pathologic varieties. Congenital lung hernias make up about 18% of all lung hernias.6 Congenital thoracic hernia usually is associated with agenesis of the ribs, sternum, or costal cartilages,2-4 and as far as we could determine, only 1 case of subtotal herniation of the lung through an intercostal space has been reported in a 16-week-old fetus.7 Other reports of congenital lung hernia refer to cervical herniation of the lung apex through a defect in Sibson’s fascia.8 Cervical herniation also has been seen with the absence of the sternocleidomastoid muscle.9 Spontaneous intercostal hernia, on the other hand, refers to the spontaneous herniation of the lung through a fascial defect in the intercostal space, usually in patients with a chronic obstructive lung disease after a bout of coughing.1,10 These patients present with a slowly increasing lateral thoracic mass, which may or may not be painful. The hernia is readily diagnosed on a Valsalva maneuver5,10 and is associated with a splaying of the affected intercostal space on the x-ray.5 A limited computed tomography of the chest with a Valsalva maneuver can also show the hernia but is necessary only if the clinical and radiologic pictures are not conclusive.10 Our patient had findings that fit typically into that of the spontaneous lung hernias. Attenuation of the fascia of the intercostal muscles was seen as in a case of spontaneous acquired intercostal hernia,1,5 and there were no visible defects in the underlying bony thorax. However, the defect visualized at surgery was presumably congenital because the bulge was noted since the age of 1 year, and there was no history of trauma or pulmonary disease. Intercostal lung hernias require treatment if they cause symptoms, or there is the risk of strangulation.1,5 A few cases of acquired spontaneous hernia have been managed conservatively by strapping and padding,11 especially if
RESENTING as an intermittent lateral thoracic bulge, herniation of the lung through a defect in the chest wall is an extremely rare condition.1 Congenital lateral lung hernias are usually associated with an underlying bony abnormality in the chest wall.2-4 Herniation of the lung through an apparently intact thoracic cage has not been reported in a child so far. We report a case of an intercostal hernia in a 7-year-old child, speculate on its type, and review the pertinent literature. CASE REPORT An 8-year-old boy presented with the complaints of an intermittent lateral bulge on the right side of the chest. The mother remembered it from when he was 1 year old, and the bulge had been growing slowly to reach its current size. There was no history of pain, and there was no history of previous trauma to the chest. On examination, a 2 ⫻ 4-cm oblong bulge was seen in the mid right sixth intercostal space when the child strained (Fig 1). The sixth intercostal space was found splayed on a x-ray, but there were no bony abnormalities of the chest wall. The underlying lungs appeared normal. The child was taken up for operative repair of the lateral lung herniation. At surgery a defect of 4 ⫻ 1 cm was found in the intercostal muscles. The fascia over the affected area had thinned out and had merged with the underlying parietal pleura. The weak fascia was excised, and a polypropylene mesh was used to fill up the gap in the intercostal space. The attenuated subcutaneous tissue and skin were closed over the mesh. Postoperatively, the child had a sterile serous wound collection, which responded to aspirations. The excised hernial sac was composed principally of pleura and had a few fibroadipose tissue fragments seen on histology.
DISCUSSION
Lung herniation is a rare entity1 and has been classified by Mevel-Levalle according to the location as cerFrom the Department of Pediatric Surgery, Kasturba Medical College, Karnataka, India. Address reprint requests to Dr Anindya Chattopadhyay, Associate Professor, Department of Pediatric Surgery, Kasturba Medical College, Manipal-576119, Karnataka, India. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3909-0028$30.00/0 doi:10.1016/j.jpedsurg.2004.05.027 1432
INDEX WORDS: Lung herniation, congenital, intercostal lung herniation.
Journal of Pediatric Surgery, Vol 39, No 9 (September), 2004: pp 1432-1433
INTERCOSTAL LUNG HERNIA
1433
there has been a history of trauma to the area. However, the majority of the patients have been treated by surgery.1 We decided to operate on the patient considering the insidious but steady growth of the mass and the risk of trauma to the herniated lung. Repair of the hernia may be accomplished primarily if there is sufficient healthy tissue to bridge the defect. The other option is to use a prosthetic mesh in the repair,1,5 as was done in our case. The repair usually is technically simple, and the results have been uniformly good.
Fig 1.
Intercostal bulge during a Valsalva maneuver.
REFERENCES 1. Brock MV, Heitmiller RF: Spontaneous anterior thoracic lung hernias. J Thorac Cardiovasc Surg 119:1046-1047, 2000 2. Neilands PS, Kurczynski TW, ElShafie MA, et al: Congenital lung herniation. Am J Med Genet 40:97-99, 1991 3. Loeff DS, Greenwald MI, Young SC, et al: A unique chest wall splint for unilateral agenesis of ribs. J Pediatr Surg 22:1129-1131, 1987 4. Rickham PP: Lung hernia secondary to congenital absence of ribs. Arch Dis Child 34:14-17, 1959 5. Ross RT, Clay MB: Atraumatic lung hernia. Ann Thorac Surg 67:1497-1499, 1999 6. Hiscoe DB, Digman GJ: Types and incidence of lung hernias. J Thorac Cardiovasc Surg 30:335-342, 1955
7. Bridger JE, Kreczy A, Wigglesworth JS: Transthoracic herniation of the fetal lung: bagpipe lung. Pediatr Pathol 12:417-423, 1992 8. Thompson JS: Cervical herniation of the lung. Report of a case and review of literature. Pediatr Radiol 4:190-192, 1976 9. Bayne SR, Lehman JA, Crow JP: Lung herniation into the neck associated with congenital absence of the sternocleidomastoid muscle. J Pediatr Surg 32:1754-1756, 1997 10. Rodney JF, Piantadosi A, Folz EK: Spontaneous intercostal bulge. Postgrad Med J 74:179-181, 1998 11. Gaude GS, Chatterji R, Bagga AS, et al: Spontaneous lung hernia. Indian J Chest Dis Allied Sci 39:65-68, 1997
The authors report a case of a lateral chest wall lung hernia, which was presumably congenital. Lung herniations are extremely rare, and congenital herniation of the lung through an apparently intact thoracic cage has not yet been reported. The hernia was repaired by the interposition of a polypropylene mesh. The literature of this rare condition is briefly reviewed.
J Pediatr Surg 39:1432-1433. © 2004 Elsevier Inc. All rights reserved.
P
vical, thoracic, or diaphragmatic.5 These groups are stratified further according to the presumed etiology as congenital or acquired; the latter group contains the traumatic, “spontaneous,” and the pathologic varieties. Congenital lung hernias make up about 18% of all lung hernias.6 Congenital thoracic hernia usually is associated with agenesis of the ribs, sternum, or costal cartilages,2-4 and as far as we could determine, only 1 case of subtotal herniation of the lung through an intercostal space has been reported in a 16-week-old fetus.7 Other reports of congenital lung hernia refer to cervical herniation of the lung apex through a defect in Sibson’s fascia.8 Cervical herniation also has been seen with the absence of the sternocleidomastoid muscle.9 Spontaneous intercostal hernia, on the other hand, refers to the spontaneous herniation of the lung through a fascial defect in the intercostal space, usually in patients with a chronic obstructive lung disease after a bout of coughing.1,10 These patients present with a slowly increasing lateral thoracic mass, which may or may not be painful. The hernia is readily diagnosed on a Valsalva maneuver5,10 and is associated with a splaying of the affected intercostal space on the x-ray.5 A limited computed tomography of the chest with a Valsalva maneuver can also show the hernia but is necessary only if the clinical and radiologic pictures are not conclusive.10 Our patient had findings that fit typically into that of the spontaneous lung hernias. Attenuation of the fascia of the intercostal muscles was seen as in a case of spontaneous acquired intercostal hernia,1,5 and there were no visible defects in the underlying bony thorax. However, the defect visualized at surgery was presumably congenital because the bulge was noted since the age of 1 year, and there was no history of trauma or pulmonary disease. Intercostal lung hernias require treatment if they cause symptoms, or there is the risk of strangulation.1,5 A few cases of acquired spontaneous hernia have been managed conservatively by strapping and padding,11 especially if
RESENTING as an intermittent lateral thoracic bulge, herniation of the lung through a defect in the chest wall is an extremely rare condition.1 Congenital lateral lung hernias are usually associated with an underlying bony abnormality in the chest wall.2-4 Herniation of the lung through an apparently intact thoracic cage has not been reported in a child so far. We report a case of an intercostal hernia in a 7-year-old child, speculate on its type, and review the pertinent literature. CASE REPORT An 8-year-old boy presented with the complaints of an intermittent lateral bulge on the right side of the chest. The mother remembered it from when he was 1 year old, and the bulge had been growing slowly to reach its current size. There was no history of pain, and there was no history of previous trauma to the chest. On examination, a 2 ⫻ 4-cm oblong bulge was seen in the mid right sixth intercostal space when the child strained (Fig 1). The sixth intercostal space was found splayed on a x-ray, but there were no bony abnormalities of the chest wall. The underlying lungs appeared normal. The child was taken up for operative repair of the lateral lung herniation. At surgery a defect of 4 ⫻ 1 cm was found in the intercostal muscles. The fascia over the affected area had thinned out and had merged with the underlying parietal pleura. The weak fascia was excised, and a polypropylene mesh was used to fill up the gap in the intercostal space. The attenuated subcutaneous tissue and skin were closed over the mesh. Postoperatively, the child had a sterile serous wound collection, which responded to aspirations. The excised hernial sac was composed principally of pleura and had a few fibroadipose tissue fragments seen on histology.
DISCUSSION
Lung herniation is a rare entity1 and has been classified by Mevel-Levalle according to the location as cerFrom the Department of Pediatric Surgery, Kasturba Medical College, Karnataka, India. Address reprint requests to Dr Anindya Chattopadhyay, Associate Professor, Department of Pediatric Surgery, Kasturba Medical College, Manipal-576119, Karnataka, India. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3909-0028$30.00/0 doi:10.1016/j.jpedsurg.2004.05.027 1432
INDEX WORDS: Lung herniation, congenital, intercostal lung herniation.
Journal of Pediatric Surgery, Vol 39, No 9 (September), 2004: pp 1432-1433
INTERCOSTAL LUNG HERNIA
1433
there has been a history of trauma to the area. However, the majority of the patients have been treated by surgery.1 We decided to operate on the patient considering the insidious but steady growth of the mass and the risk of trauma to the herniated lung. Repair of the hernia may be accomplished primarily if there is sufficient healthy tissue to bridge the defect. The other option is to use a prosthetic mesh in the repair,1,5 as was done in our case. The repair usually is technically simple, and the results have been uniformly good.
Fig 1.
Intercostal bulge during a Valsalva maneuver.
REFERENCES 1. Brock MV, Heitmiller RF: Spontaneous anterior thoracic lung hernias. J Thorac Cardiovasc Surg 119:1046-1047, 2000 2. Neilands PS, Kurczynski TW, ElShafie MA, et al: Congenital lung herniation. Am J Med Genet 40:97-99, 1991 3. Loeff DS, Greenwald MI, Young SC, et al: A unique chest wall splint for unilateral agenesis of ribs. J Pediatr Surg 22:1129-1131, 1987 4. Rickham PP: Lung hernia secondary to congenital absence of ribs. Arch Dis Child 34:14-17, 1959 5. Ross RT, Clay MB: Atraumatic lung hernia. Ann Thorac Surg 67:1497-1499, 1999 6. Hiscoe DB, Digman GJ: Types and incidence of lung hernias. J Thorac Cardiovasc Surg 30:335-342, 1955
7. Bridger JE, Kreczy A, Wigglesworth JS: Transthoracic herniation of the fetal lung: bagpipe lung. Pediatr Pathol 12:417-423, 1992 8. Thompson JS: Cervical herniation of the lung. Report of a case and review of literature. Pediatr Radiol 4:190-192, 1976 9. Bayne SR, Lehman JA, Crow JP: Lung herniation into the neck associated with congenital absence of the sternocleidomastoid muscle. J Pediatr Surg 32:1754-1756, 1997 10. Rodney JF, Piantadosi A, Folz EK: Spontaneous intercostal bulge. Postgrad Med J 74:179-181, 1998 11. Gaude GS, Chatterji R, Bagga AS, et al: Spontaneous lung hernia. Indian J Chest Dis Allied Sci 39:65-68, 1997