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Acquired Spontaneous Intercostal Hernia of the Lung Diagnosed on Helical CT

Nuovo Pellegrini Hospital 80100 Naples, Italy
Second University of Naples 80138 Naples, Italy
"Federico II" University of Naples 80131 Naples, Italy

A 19-year-old man presented to our department with a 6-month history of a soft bulge in the right anterior middle region of the chest wall with volume of the bulge increasing during coughing or Valsalva's maneuver. We studied the mass primarily with sonography (Fig. 3A) and noted that the muscular structure was not clearly visible in the intercostal scan. A right posteroanterior chest radiograph revealed a fifth intercostal space larger than normal (Fig. 3B). CT of the thorax was performed during a single suspended respiration on inspiration (Fig. 3C). The prior scans did not show any abnormality of the lung parenchyma or fractures of the rib cage; nevertheless, the helical CT performed during Valsalva's maneuver revealed a segment of the right lung parenchyma protruding beyond the thoracic cage into the subcutaneous space (Fig. 3D). The precise location and size of the protrusion were clearly shown. Hernias of the lung are classified as cervical, intercostal, or diaphragmatic, and each of these types can be either congenital or acquired. A congenital hernia can be detected in an infant as an incidental finding on a chest radiograph; the acquired hernias can be classified as traumatic, spontaneous, or pathologic when they occur after neoplastic or inflammatory processes [1,2,3]. The spontaneous intercostal hernias are rare clinical entities [4]. Usually, their location is in the parasternal region because of the lack of external intercostal muscles, but a decreased acquired or congenital thoracic wall resistance may be the first cause of herniation of the lung. This resistance has been described as a mechanism of muscular tear after blunt thoracic trauma, when the intercostal muscle exists as a single internal or external layer and the ribs deform excessively without fracture. The force is transferred to the single-layered intercostal muscle, which tears. Our young patient did not recall any previous traumatic event; the appearance of the bulge on the right thorax, which enlarged on deep inspiration from coughing, was really asymptomatic. Helical CT is the most valuable technique for detecting pulmonary herniation. This examination helps clinicians assess the pathologic condition and evaluate the possibility of surgery in case of strangulation.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —19-year-old man with acquired spontaneous hernia of lung. Sonographic examination of bulge does not show muscular structures clearly.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —19-year-old man with acquired spontaneous hernia of lung. Chest radiograph shows fifth intercostal space (arrows) is larger than normal.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —19-year-old man with acquired spontaneous hernia of lung. Helical CT scan shows healthy right chest.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —19-year-old man with acquired spontaneous hernia of lung. Helical CT scan obtained during Valsalva's maneuver shows pulmonary parenchyma protruding from thoracic cavity.

References

1. Serpell JW, Johnson WR. Traumatic diaphragmatic hernia presenting as an intercostal hernia: case report. J Trauma 1994;38:421-423
2. La Hei ER, Deal CW. Intercostal lung hernia subsequent to harvesting of the left internal mammary artery. Ann Thorac Surg 1995;59:1579-1580[Abstract/Free Full Text]
3. May AK, Chan B, Daniel TM, Young JS. Anterior lung herniation: another aspect of the seatbelt syndrome. J Trauma 1995;38:587-589[Medline]
4. Bhalla M, Leitman BS, Forcade C, Stern E, Naidich DP, McCauley DI. Lung hernia: radiographic features. AJR 1990;154:51-53[Abstract/Free Full Text]

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This Article Figures Only Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tamburro, F. Articles by Vecchio, W. D. Search for Related Content PubMed PubMed Citation Articles by Tamburro, F. Articles by Vecchio, W. D. Social Bookmarking                      What's this?