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Lung hernia
Lung Hernia CHRIS GLENN, MD,* WILLIAM BONEKAT, DO,-I ANASTASIA CUA, MD,:I: DAVID CHAPMAN, MD,§ RUSSELL McFALL, MD* Lung hernia is an uncommon entity usually resulting from trauma or inadequate healing from recent or remote thoracic surgery. A small percentage may be congenital. Four cases are reported, each demonstrating lung herniation resulting from either accidental or postsurgical trauma. Most of the previous cases have been reviewed in various surgical and radiological journals with only rare mention in the emergency medicine literature. Because emergency physicians may be the most immediate contact for patients who develop a lung herniation, they should be cognizant of this entity as a possible delayed complication to chest wall injury. Awareness of the clinical and radiological appearance of lung hernia will help to avoid its confusion with other conditions such as subcutaneous emphysema, chest tumor, pneumothorax, or a focus of infection. (Am J Emerg Meal 1997;15:260-263. Copyright © 1997 by W.B, Saunders Company) CASE1 A 34-year-old man was riding a bicycle at approximately 20 miles per hour and was impaled in his left chest when a car door was opened in his path. He suffered a large left anterior chest wall laceration just below the clavicle at approximately the second intercostal space with subsequent herniation of the left lung through this soft tissue defect. The paramedics brought him to the emergency department (ED) with complaints of shortness of breath and left chest wall pain. On initial physical exam he was noted to have a laceration 6 to 10 cm over his left chest wall with lung tissue herniated both superiorly and anteriorly. His breath sounds were decreased on the left side. Other findings were consistent with lacerations and abrasions of his limbs, none serious. In the El) an anteroposterior film of the chest showed a left-sided pneumothorax with a confluent horizontal lucency in the overlying soft tissues representing herniated lung tissue (Figure 1). Surrounding lung contusion was also noted. A left chest tube was placed, with resolution of the pneumothorax. The lung herniation spontaneously reduced in the ED with a large inspiration. Because of the location and severity of the injury, an arch angiogram and angiogram of the left subclavian vessels were obtained and found to be normal. The patient was taken to the operating room for exploration of the wound, irrigation of the left chest cavity, and dressing. The wound was left open to the level of the pectoralis major muscle with plans for delayed primary closure at an outside facility to satisfy insurance stipulations. The chest tube was placed on water seal from wall suction on hospital day 3 with complete resolution of the
From the *Department of Radiology and l-Division of Pulmonary and Critical Care Medicine, University of California, Davis; the :~Department of Dermatology, University of California, San Francisco; and the §Department of Medicine, Veterans Affairs Medical Center, Martinez, CA. Manuscript received November 12, 1995; accepted January 10, 1996. Address reprint requests to Dr Glenn, 5112 Parque Vista Way, Carmichael, CA 95608. Key Words:Lung hernia, traumatic, postsurgical, CT. Copyright © 1997 by W.B. Saunders Company 0735-6757/97/1503-001055.00/0 260
pneumothorax, and the patient was transferred to an outside hospital the following day.
CASE 2 A 71-year-old man was evaluated at a local hospital in November 1990 because of left rib pains after a paroxysm of cough. No acute rib fracture was detected and conservative management was instituted with mild analgesia as needed for pain. In December 1990 the patient again had a coughing spell, causing him to fall against his back. He did not seek medical attention at that time, but because of persistent left chest pain he saw his physician and a chest x-ray was performed on 1/7/91. A pneumothorax was not evident, but a subplural collection of serous fluid or blood was considered to be present in the left lateral pleural space. Recent fractures of the lateral aspect of the 6th and 7th ribs were found. There also appeared to be a small area of lung herniation. The patient was advised to wear a rib binder, and conservative management was continued. Over the next month the patient continued to complain of left lower rib pain and he now noted a "puffiness" at the site of the rib fractures. This was particularly noticeable if the patient coughed. A repeat chest film (Figure 2) on 2/28/91 showed a worsening of the left lung herniation and was further confirmed by computed tomography (CT) of the chest (Figure 3). On physical examination there was a soft, bulging mass palpated along the left lower margin of his chest which was especially prominent while performing a Valsalva maneuver. CT of the chest confirmed the presence of a herniated left lower lobe through the region of his rib fractures and through the oblique serratus anterior musculature. The patient had a 50 pack-year smoking history but had quit 2 years earlier. The patient also had been on chronic low-dose prednisone (7.5 rag/d) for 1 and a half years. He was evaluated for possible surgical repair of the hernia but was considered to be at high surgical risk because of his poor pulmonary function. The patient was advised to continue his rib binder as needed and was given instructions for follow-up in the outpatient clinic. The patient's pain gradually subsided over the ensuing weeks, although he continued to have a noticeable bulge along his left chest area with cough.
CASE 3 A 35-year-old man with long-standing interstitial fibrosis and bronchiolitis obliterans with organizing pneumonia was well until February of 1986 when he began to experience shortness of breath. A chest X-ray showed bibasilar infiltrates, and pulmonary function tests revealed a restrictive pattern. He also was noted to have a low platelet count and was treated for idiopathic thrombocytopenia with resolution following a splenectomy and steroid therapy. His lung disease progressed and in July of 1986 he had a lung biopsy that showed active inflammatory process with mixed B and T lymphocytes. Administration of azothioprine and then prednisone was begun. His lung biopsy was complicated by cellulitis which resolved without incident. Because of his heavy exposure to birds throughout his life (he had more than 100 birds at any one time), it was believed that his underlying lung disorder was hypersensitivity
GLENN ET AL • LUNG HERNIA
FIGURE 1. Case l: 34-year-old man impaled on a car door during a bicycle accident. He suffered a traumatic lung herniation involving his left upper chest. pneumonitis (bird fanciers' lung). He had a severe chronic cough, and this, in addition to his chronic prednisone use, probably contributed to the development of a lung hernia which was noted in January of 1980 at the site of his lung biopsy incision (Figure 4). This hernia was through a chest wall defect, which bulged with cough and Valsalva. The patient was referred for surgical evaluation because the herniation was intermittently symptomatic, although the symptoms were mild. Because of the patient's cough, obesity, and significant pulmonary disease, repair posed undue risk and was not performed. This patient died from his pulmonary disease 2 years after his lung hernia was discovered.
261
FIGURE 3. Case 2: Axial CT image demonstrating a left lower lobe lung herniation provides additional information regarding size and characteristics of the involved lung and the surrounding parenchyma. thought to be due to anatomic changes postoperatively. A bronchoscopy showed redundant pharyngeal tissue and membranous tracheal collapse. On physical exam the patient was found to have a small hernia of the right anterior chest wall at the level of the ninth rib which was verified by CT (Figure 5). The hernia was thought to be related to the patient's previous surgery. The patient denied any symptomatology related to the lung hernia and no intervention was planned.
CASE 4
DISCUSSION
A 56-year-old man who was a farmer had a left thoracotomy in 1986 for ascending aortic aneurysm repair following a traumatic dissection. His wife noted a loud expiratory wheeze at night for which he was evaluated by his physician. At the time of evaluation the patient experienced a "choking sensation and cough" with "raspy breathing, high in the chest and low in the throat" unrelated to patient position. He reported no fever, chills, night sweats, weight loss, or change in exercise tolerance, and the wheezing was
Lung hernia, defined as a protrusion of the pulmonary tissue beyond the normal confines of the thoracic cage, is a rarity. To date, fewer than 300 cases have been reported. 1 Herniation of the lung was classified according to localization and etiology as early as 1847 by Morel-Lavelle 2 (Table 1). On the basis of location, cervical hernias account for about 35% of lung hernias and present usually as a bulge through Sibson's fascia, which is located at the apex of the thorax between the scalene anterior and sternocleidomastoid muscles. 3,4 Cervical hernias are usually congenital in origin.
FIGURE 2. Case 2: 71-year-old man with chronic obstructive pulmonary disease who was taking chronic low-dose prednisone. He developed a traumatic lung hernia at the site of previous rib fractures.
FIGURE 4. Case 3: 35-year-old man with interstitial fibrosis and bronchiolitis obliterans with organizing pneumonia treated with prednisone. He developed a lung hernia at the site of his lung biopsy incision.
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 15, Number 3 • May 1997
FIGURE 5. Case 4: 56-year-old farmer who was noted to have a small, asymptomatic anterior lung hernia during a physical exam for an unrelated problem. The hernia was believed to be secondary to previous surgery. The remaining 65% are thoracic in location, most commonly found at sites of previous injury or surgery, ie, posttraumatic. They may also originate at anatomically weak sites along thoracic intercostal spaces, such as anteriorly, near the costochondral junction, and posteriorly, in intercostal spaces adjacent to the vertebral bodies. 4 These are usually a result of increased intrathoracic pressure.5 A single case of diaphragmatic lung hernia was reported by Beale in 18826 but no other case has been substantiated since that time. Herniation has been distinguished from lung prolapse by some authors; herniation occurs when lung is covered by mesothelium and skin, and prolapse is lung outside the thorax through a disrupted pleura. 1 For the purpose of this discussion, these entities are considered as one. On the basis of etiology, congenital hernias account for 18% of lung herniation and frequently occur as developmental defects in the supraclavicular fossa or at the costochondral junction. 5 Acquired hernias make up the rest, as seen in the cases presented here. About half of these are traumatic in nature, often occurring at a site of injury following a penetrating wound (Case 1), fracture of ribs (Case 2), or after surgery (Cases 3 and 4). A common location for posttraumatic hernia is parasternal. 5 Lung hernias may not become apparent for several weeks to years after trauma, and have been referred to in the older literature as "consecutive." 1This term is rarely used anymore, because hernias are TABLE 1. Classification of Lung HerniaAccording to Location and Etiology
Location Cervical Thoracic Diaphragmatic Etiology Congenital Acquired Traumatic Spontaneous Pathologic
seldom observed immediately after injury. Spontaneous hernias occur in association with increased intrathoracic pressure, as may be generated with protracted coughing, the Valsalva maneuver, or during heavy lifting. Other predisposing factors include chronic obstructive pulmonary disease, most likely related to chronic, forceful coughing, lung hyperinflation, and chronic steroid use (Cases 2 and 3). Pathologic hernias are usually secondary to any locally active process and include neoplastic and inflammatory processes, such as chest wall abscess, empyema, or tuberculous osteitis5 Pathologic hernias are rare because of improved early medical intervention. Lung hernia usually presents with few symptoms. A bulging, spongy, crepitant mass can be palpated as it protrudes from the chest wall. It is discrete, increasing in size with expiration and decreasing or disappearing with inspiration. Pain or tenderness may be elicited upon palpating the area around the chest wall defect. An important diagnostic sign is the finding that the mass increases in size during the Valsalva maneuver, coughing, or straining. The mass should then diminish in size during inspiration or quiet breathing, v Chest radiographs or lateral radiographs of the neck visualize most cervical hernias. An optimal oblique view of the chest, with the central x-ray beam directed at a true tangent to the site of the defect, may be necessary to visualize herniation through the intercostal space. CT of the chest, however, not only provides dimensions of the hernia and information about the thoracic cage and pleural space, but also helps establish an ongoing neoplastic or inflammatory process. 8 It may also be helpful in differentiating other chest wall conditions such as traumatic subcutaneous emphysema. In general, lung hernias are asymptomatic. Although spontaneous regression is uncommon, conservative management is the treatment of choice. Strapping of the hernia site may be of added benefit. Surgical repair is indicated in cases of incarceration, pain, recurrent infection, and airway obstruction. 9 Cosmesis can be achieved by a local plastic procedure utilizing a synthetic or preferably an autologous tissue patchJ Recognizing lung herniation is important for the ED physician, who is often the first contact a person with this entity may have with the medical community. Identifying lung herniation without delay may avoid invasive treatment, unnecessary workup, and therapy that is not beneficial and may be harmful to the patient. REFERENCES
1. Scullion D, Negus R, AI-Kutoubi A: Case report: Extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994;67:94-96 2. MoreI-Lavelle A: Hernies du poumon. Bull Soc Chir Paris 1847;1:75 3. Bidstrup P, Nordentoft JM, Petersen B: Hernia of the lung: Brief survey and report of two cases. Acta Radio11966;4:490-496 4. Hiscoe DB, Digman GJ: Types and incidence of lung hernias. J Thorac Surg 1955;30:335-342 5. Saw C, Yokoyama T, Lee B, Sargent EN: Intercostal pulmonary hernia. Arch Surg 1976;111:548-551 6. Beale EC: On a case of hernia of lung through the diaphragm. Lancet 1882;1:139 7. Munnell ER: Herniation of the lung. Ann Thorac Surg 1968;5:204212 8. Fraser RG, Pare JAP: Diagnosis of diseases of the chest (ed 2). Philadelphia, PA, Saunders, 1979 9. Gonzalez J, Cunha C: Cervical lung herniation associated with upper airway obstruction. Ann Emerg Med 1990;19:935-937
From the *Department of Radiology and l-Division of Pulmonary and Critical Care Medicine, University of California, Davis; the :~Department of Dermatology, University of California, San Francisco; and the §Department of Medicine, Veterans Affairs Medical Center, Martinez, CA. Manuscript received November 12, 1995; accepted January 10, 1996. Address reprint requests to Dr Glenn, 5112 Parque Vista Way, Carmichael, CA 95608. Key Words:Lung hernia, traumatic, postsurgical, CT. Copyright © 1997 by W.B. Saunders Company 0735-6757/97/1503-001055.00/0 260
pneumothorax, and the patient was transferred to an outside hospital the following day.
CASE 2 A 71-year-old man was evaluated at a local hospital in November 1990 because of left rib pains after a paroxysm of cough. No acute rib fracture was detected and conservative management was instituted with mild analgesia as needed for pain. In December 1990 the patient again had a coughing spell, causing him to fall against his back. He did not seek medical attention at that time, but because of persistent left chest pain he saw his physician and a chest x-ray was performed on 1/7/91. A pneumothorax was not evident, but a subplural collection of serous fluid or blood was considered to be present in the left lateral pleural space. Recent fractures of the lateral aspect of the 6th and 7th ribs were found. There also appeared to be a small area of lung herniation. The patient was advised to wear a rib binder, and conservative management was continued. Over the next month the patient continued to complain of left lower rib pain and he now noted a "puffiness" at the site of the rib fractures. This was particularly noticeable if the patient coughed. A repeat chest film (Figure 2) on 2/28/91 showed a worsening of the left lung herniation and was further confirmed by computed tomography (CT) of the chest (Figure 3). On physical examination there was a soft, bulging mass palpated along the left lower margin of his chest which was especially prominent while performing a Valsalva maneuver. CT of the chest confirmed the presence of a herniated left lower lobe through the region of his rib fractures and through the oblique serratus anterior musculature. The patient had a 50 pack-year smoking history but had quit 2 years earlier. The patient also had been on chronic low-dose prednisone (7.5 rag/d) for 1 and a half years. He was evaluated for possible surgical repair of the hernia but was considered to be at high surgical risk because of his poor pulmonary function. The patient was advised to continue his rib binder as needed and was given instructions for follow-up in the outpatient clinic. The patient's pain gradually subsided over the ensuing weeks, although he continued to have a noticeable bulge along his left chest area with cough.
CASE 3 A 35-year-old man with long-standing interstitial fibrosis and bronchiolitis obliterans with organizing pneumonia was well until February of 1986 when he began to experience shortness of breath. A chest X-ray showed bibasilar infiltrates, and pulmonary function tests revealed a restrictive pattern. He also was noted to have a low platelet count and was treated for idiopathic thrombocytopenia with resolution following a splenectomy and steroid therapy. His lung disease progressed and in July of 1986 he had a lung biopsy that showed active inflammatory process with mixed B and T lymphocytes. Administration of azothioprine and then prednisone was begun. His lung biopsy was complicated by cellulitis which resolved without incident. Because of his heavy exposure to birds throughout his life (he had more than 100 birds at any one time), it was believed that his underlying lung disorder was hypersensitivity
GLENN ET AL • LUNG HERNIA
FIGURE 1. Case l: 34-year-old man impaled on a car door during a bicycle accident. He suffered a traumatic lung herniation involving his left upper chest. pneumonitis (bird fanciers' lung). He had a severe chronic cough, and this, in addition to his chronic prednisone use, probably contributed to the development of a lung hernia which was noted in January of 1980 at the site of his lung biopsy incision (Figure 4). This hernia was through a chest wall defect, which bulged with cough and Valsalva. The patient was referred for surgical evaluation because the herniation was intermittently symptomatic, although the symptoms were mild. Because of the patient's cough, obesity, and significant pulmonary disease, repair posed undue risk and was not performed. This patient died from his pulmonary disease 2 years after his lung hernia was discovered.
261
FIGURE 3. Case 2: Axial CT image demonstrating a left lower lobe lung herniation provides additional information regarding size and characteristics of the involved lung and the surrounding parenchyma. thought to be due to anatomic changes postoperatively. A bronchoscopy showed redundant pharyngeal tissue and membranous tracheal collapse. On physical exam the patient was found to have a small hernia of the right anterior chest wall at the level of the ninth rib which was verified by CT (Figure 5). The hernia was thought to be related to the patient's previous surgery. The patient denied any symptomatology related to the lung hernia and no intervention was planned.
CASE 4
DISCUSSION
A 56-year-old man who was a farmer had a left thoracotomy in 1986 for ascending aortic aneurysm repair following a traumatic dissection. His wife noted a loud expiratory wheeze at night for which he was evaluated by his physician. At the time of evaluation the patient experienced a "choking sensation and cough" with "raspy breathing, high in the chest and low in the throat" unrelated to patient position. He reported no fever, chills, night sweats, weight loss, or change in exercise tolerance, and the wheezing was
Lung hernia, defined as a protrusion of the pulmonary tissue beyond the normal confines of the thoracic cage, is a rarity. To date, fewer than 300 cases have been reported. 1 Herniation of the lung was classified according to localization and etiology as early as 1847 by Morel-Lavelle 2 (Table 1). On the basis of location, cervical hernias account for about 35% of lung hernias and present usually as a bulge through Sibson's fascia, which is located at the apex of the thorax between the scalene anterior and sternocleidomastoid muscles. 3,4 Cervical hernias are usually congenital in origin.
FIGURE 2. Case 2: 71-year-old man with chronic obstructive pulmonary disease who was taking chronic low-dose prednisone. He developed a traumatic lung hernia at the site of previous rib fractures.
FIGURE 4. Case 3: 35-year-old man with interstitial fibrosis and bronchiolitis obliterans with organizing pneumonia treated with prednisone. He developed a lung hernia at the site of his lung biopsy incision.
262
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 15, Number 3 • May 1997
FIGURE 5. Case 4: 56-year-old farmer who was noted to have a small, asymptomatic anterior lung hernia during a physical exam for an unrelated problem. The hernia was believed to be secondary to previous surgery. The remaining 65% are thoracic in location, most commonly found at sites of previous injury or surgery, ie, posttraumatic. They may also originate at anatomically weak sites along thoracic intercostal spaces, such as anteriorly, near the costochondral junction, and posteriorly, in intercostal spaces adjacent to the vertebral bodies. 4 These are usually a result of increased intrathoracic pressure.5 A single case of diaphragmatic lung hernia was reported by Beale in 18826 but no other case has been substantiated since that time. Herniation has been distinguished from lung prolapse by some authors; herniation occurs when lung is covered by mesothelium and skin, and prolapse is lung outside the thorax through a disrupted pleura. 1 For the purpose of this discussion, these entities are considered as one. On the basis of etiology, congenital hernias account for 18% of lung herniation and frequently occur as developmental defects in the supraclavicular fossa or at the costochondral junction. 5 Acquired hernias make up the rest, as seen in the cases presented here. About half of these are traumatic in nature, often occurring at a site of injury following a penetrating wound (Case 1), fracture of ribs (Case 2), or after surgery (Cases 3 and 4). A common location for posttraumatic hernia is parasternal. 5 Lung hernias may not become apparent for several weeks to years after trauma, and have been referred to in the older literature as "consecutive." 1This term is rarely used anymore, because hernias are TABLE 1. Classification of Lung HerniaAccording to Location and Etiology
Location Cervical Thoracic Diaphragmatic Etiology Congenital Acquired Traumatic Spontaneous Pathologic
seldom observed immediately after injury. Spontaneous hernias occur in association with increased intrathoracic pressure, as may be generated with protracted coughing, the Valsalva maneuver, or during heavy lifting. Other predisposing factors include chronic obstructive pulmonary disease, most likely related to chronic, forceful coughing, lung hyperinflation, and chronic steroid use (Cases 2 and 3). Pathologic hernias are usually secondary to any locally active process and include neoplastic and inflammatory processes, such as chest wall abscess, empyema, or tuberculous osteitis5 Pathologic hernias are rare because of improved early medical intervention. Lung hernia usually presents with few symptoms. A bulging, spongy, crepitant mass can be palpated as it protrudes from the chest wall. It is discrete, increasing in size with expiration and decreasing or disappearing with inspiration. Pain or tenderness may be elicited upon palpating the area around the chest wall defect. An important diagnostic sign is the finding that the mass increases in size during the Valsalva maneuver, coughing, or straining. The mass should then diminish in size during inspiration or quiet breathing, v Chest radiographs or lateral radiographs of the neck visualize most cervical hernias. An optimal oblique view of the chest, with the central x-ray beam directed at a true tangent to the site of the defect, may be necessary to visualize herniation through the intercostal space. CT of the chest, however, not only provides dimensions of the hernia and information about the thoracic cage and pleural space, but also helps establish an ongoing neoplastic or inflammatory process. 8 It may also be helpful in differentiating other chest wall conditions such as traumatic subcutaneous emphysema. In general, lung hernias are asymptomatic. Although spontaneous regression is uncommon, conservative management is the treatment of choice. Strapping of the hernia site may be of added benefit. Surgical repair is indicated in cases of incarceration, pain, recurrent infection, and airway obstruction. 9 Cosmesis can be achieved by a local plastic procedure utilizing a synthetic or preferably an autologous tissue patchJ Recognizing lung herniation is important for the ED physician, who is often the first contact a person with this entity may have with the medical community. Identifying lung herniation without delay may avoid invasive treatment, unnecessary workup, and therapy that is not beneficial and may be harmful to the patient. REFERENCES
1. Scullion D, Negus R, AI-Kutoubi A: Case report: Extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994;67:94-96 2. MoreI-Lavelle A: Hernies du poumon. Bull Soc Chir Paris 1847;1:75 3. Bidstrup P, Nordentoft JM, Petersen B: Hernia of the lung: Brief survey and report of two cases. Acta Radio11966;4:490-496 4. Hiscoe DB, Digman GJ: Types and incidence of lung hernias. J Thorac Surg 1955;30:335-342 5. Saw C, Yokoyama T, Lee B, Sargent EN: Intercostal pulmonary hernia. Arch Surg 1976;111:548-551 6. Beale EC: On a case of hernia of lung through the diaphragm. Lancet 1882;1:139 7. Munnell ER: Herniation of the lung. Ann Thorac Surg 1968;5:204212 8. Fraser RG, Pare JAP: Diagnosis of diseases of the chest (ed 2). Philadelphia, PA, Saunders, 1979 9. Gonzalez J, Cunha C: Cervical lung herniation associated with upper airway obstruction. Ann Emerg Med 1990;19:935-937