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

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.