Severe Mediastinal Emphysema and Tension Pneumothorax Caused by Cough-Induced Intercostal Lung Herniation

Shinjiro Mizuguchi, Masahide Kaji, Toshihiko Yoshida, Takeshi Iwasaki, Takao Kamimori, Hiroshi Fujiwara

Department of Surgery, National Hospital Organization, Kobe Medical Center, Kobe, Japan.
Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan.
Respiratory Center, Yodogawa Christian Hospital, Osaka, Japan.

DOI: 10.4236/ojts.2014.41001                

Abstract

We report a case of cough-induced intercostal lung herniation with severe mediastinal emphysema and pneumothorax. A 60-year-old overweight man was admitted with dyspnea, chest pain, and chest wall bulging. Imaging confirmed left pneumothorax, fractures of the 8th to 10th ribs, and a defect in the 8th intercostal muscles. The presence of protrusion of lung parenchyma outside the intercostal space was unclear. Although the symptoms of tension pneumothorax disappeared after drainage, the subcutaneous emphysema was uncontrollable. Emergency surgery revealed lung injury near the 8th rib wedge not directly related to the rib fracture, and lung herniation was observed. We performed direct approximation of the ribs, and the lung parenchymal surface was encased by absorbable materials, avoiding infection risk. Although the lung herniation recurred 5 months later, the patient did not desire additional surgical repair. Non-absorbable materials should be considered for repair of lung herniation, excluding patients at high infection risk.

Keywords

Intercostal Lung Herniation; Cough/Sneeze; Surgical Procedure

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Weissberg, D. and Refaely, Y (2002) Hernia of the Lung. The Annals of Thoracic Surgery, 74, 1963-1966. http://dx.doi.org/10.1016/S0003-4975(02)04077-8
[2]	Ross, R.T. and Burnett, C.M. (1999) Atraumatic Lung Hernia. The Annals of Thoracic Surgery, 67, 1496-1497. http://dx.doi.org/10.1016/S0003-4975(99)00225-8
[3]	Goverde, P., Van Schil, P., Van den Brande, F. and Vanmaele, R. (1998) Chronic Herniation of the Lung in a Patient with Chronic Obstructive Pulmonary Disease. Case Report and Review of the Literature. The Thoracic and Cardiovascular Surgeon, 46, 164-166. http://dx.doi.org/10.1055/s-2007-1010219
[4]	Brock, M.V. and Heitmiller, R.F. (2000) Spontaneous Anterior Thoracic Lung Hernias. The Journal of Thoracic and Cardiovascular Surgery, 119, 1046-1047. http://dx.doi.org/10.1016/S0022-5223(00)70103-6
[5]	Tack, D., Wattiez, A., Schtickzelle, J.C. and Delcour, C. (2000) Spontaneous Lung Herniation after a Single Cough. European Radiology, 10, 500-502. http://dx.doi.org/10.1007/s003300050084
[6]	Szentkereszty, Z., Boros, M., Sápy, P. and Kiss, S.S. (2006) Surgical Treatment of Intercostal Hernia with Implantation of Polypropylene Mesh. Hernia, 10, 354-356. http://dx.doi.org/10.1007/s10029-005-0035-5
[7]	Sulaiman, A., Cottin, V., De Souza Neto, E.P., et al. (2006) Cough-Induced Intercostal Lung Herniation Requiring Surgery: Report of A Case. Surgery Today, 36, 978-980. http://dx.doi.org/10.1007/s00595-006-3284-8
[8]	Jastrow, K.M., Chu, D., Jaroszewski, D., et al. (2009) Posterior Lung Herniation after a Coughing Spell: A Case Report. Cases Journal, 2, 86. http://dx.doi.org/10.1186/1757-1626-2-86
[9]	Shankar, S. and Abbas, A. (2010) Acute Respiratory Failure Caused by Spontaneous Herniation of the Lung. The Ochsner Journal, 10, 256-258.
[10]	Mirza, A., Gogna, R., Kumaran, M., Malik, M. and Martin-Ucar, A.E. (2011) The Surgical Management of Intercostal Lung Herniation Using Bioprosthesis. Journal of Surgical Case Reports, 2, 6.
[11]	O’Shea, M. and Cleasby, M. (2012) Images in Clinical Medicine. Lung Herniation after Cough-Induced Rupture of Intercostal Muscle. The New England Journal of Medicine, 366, 74. http://dx.doi.org/10.1056/NEJMicm1106070
[12]	Wiens, S., Hunt, I., Mahood, J., et al. (2009) Novel Fixation Technique for the Surgical Repair of Lung Hernias. The Annals of Thoracic Surgery, 88, 1034-1035. http://dx.doi.org/10.1016/j.athoracsur.2008.12.032