Disorders of the Mediastinum: Pleura and Chest Wall |

Spontaneous Intercostal Lung Herniation FREE TO VIEW

Ian Lee, DO; Ching-Fei Chang, MD
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University of Southern California, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A229. doi:10.1016/j.chest.2016.02.237
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SESSION TITLE: Pleura and Chest Wall

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Spontaneous intercostal lung herniation is a very rare condition. We present an unusual case of a lateral chest wall intercostal lung herniation in an obese male smoker. In our patient, conservative therapy was recommended, although reliance on narcotic pain medication may be an argument for surgical intervention in the future.

CASE PRESENTATION: A 53-year-old obese man with a 70-pack-year history of smoking presented with coughing for one week. After one particularly violent episode, he noticed pain and bruising around his left lateral chest area extending down to the flank. A CT scan revealed intercostal herniation of the left lung between the seventh and eighth ribs, with an associated hematoma and soft tissue edema extending from the mid-axillary line down to the level of the anterosuperior iliac spine. Thoracic surgery recommended that the patient be treated with conservative management because a thoracotomy and chest wall reconstruction could potentially worsen his symptoms. Subsequent follow up CT scans showed no change in the lung perfusion or edema, but there was gradual improvement in the pleural disease over time. Currently, he still relies on daily pain medication, but has not required surgical intervention for hemoptysis, infections, or other complications.

DISCUSSION: There are less than 25 cases of non-traumatic intercostal lung herniation documented in the literature, mostly due to abrupt changes in intrathoracic pressure in an area of pre-existing chest wall weakness. The most common cause is severe coughing, although there are reports of lung herniation following more esoteric triggers, such as playing a wind instrument.1 Risk factors appear to be male gender, obesity, and smoking. The most frequent location is in the anterior thorax, between the 8th and 9th ribs, due to the absence of adequate muscular support, especially in the parasternal region. In contrast, the posterior thoracic wall is well-protected due to the presence of the trapezius, latissimus dorsi, and rhomboid muscles.

CONCLUSIONS: Intercostal lung herniation is frequently managed conservatively with compressive pads, corsets, and analgesics while the underlying cause resolves. Surgical correction is reserved for cases in which symptoms suggest lung incarceration, such as pain, hemoptysis or recurrent infections. However, some experts feel that these hernias are unlikely to resolve spontaneously, and that ironically, a small defect increases the risk of incarceration and ultimately makes reduction in the future more difficult.1 Therefore, the decision for surgery should be reconsidered if the symptoms do not improve over time.

Reference #1: Goverde, et al. Thorac Cardiovasc Surg 1998;46

DISCLOSURE: The following authors have nothing to disclose: Ian Lee, Ching-Fei Chang

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