SPONTANEOUS LUNG HERNIATION AFTER SNEEZING

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung herniation is defined as a protrusion of the pulmonary tissue and pleural membranes beyond the confines of the thoracic cavity through an abnormal opening in the chest wall, diaphragm or mediastinum [1-2]. Pulmonary hernias are extremely rare and usually secondary to a traumatic event, or a surgical procedure. Spontaneous lung herniation is rarely reported in the medical literature. We are presenting a case of spontaneous left lung herniation after an episode of sneezing. CASE PRESENTATION: A 59-year-old man with a past medical history of hypertension, chronic leg edema, and morbid obesity presented with abdominal pain. He reported having a sneeze while sitting and felt popping sensation into his abdomen, followed by severe left lower chest pain and cough. There were no prior infectious symptoms including fever, chills, or night sweats. No associated wheezing or hoarseness of voice. No recent weight changes, worsening of leg edema, orthopnea or paroxysmal nocturnal dyspnea reported. The physical exam is noted to have bruising in the anterior and lateral abdominal wall (Figure 1) with edema and bilateral leg swelling. Laboratory work-up was unremarkable. Computed Tomography (CT) scan of the abdomen and pelvis (Figure 2) showed diffuse anterior wall edema, asymmetrical herniation of the left lung, and adjacent pleural fluid consistent with the diagnosis of left lung herniation into the abdominal wall. He underwent left diagnostic video-assisted thoracoscopic surgery due to persistent refractory chest wall pain. Intraoperative findings were consistent with 4 centimeters (cm) vertical defect between 8th and 9th ribs span the entire length of the chest, approximately 15 cm. Subsequently he underwent left thoracotomy with defect repair. The postoperative course was unremarkable. He was discharged from the hospital without recurring symptoms. DISCUSSION: Spontaneous lung hernia results from an excessive increase in intrathoracic pressure, and strain which forces a portion of the lung through a relatively weak area in the chest wall. Uncomplicated lung hernia can be asymptomatic; however, the common presentation is a soft, tender, subcutaneous mass that enlarges on physical strain or coughing. In the absence of a palpable mass, the Valsalva maneuver will usually cause the bulge to appear. CT scan is necessary to assess the exact location and size of the defect which both will affect the subsequent management. Both surgical and conservative management has been recommended. Asymptomatic hernias usually require no treatment. Increasing size, pain, and any sign of impending incarceration are the main indication for surgical repair. CONCLUSIONS: Lung herniation, despite being uncommon, is important to diagnosis to avoid potential complications of lung tissue strangulation. The clinical presentation and physical examination should raise suspicion and prompt diagnostic workup for lung herniation. Reference #1: Donato AT, Hipona FA, Navani S. Spontaneous lung hernia. Chest. 1973 Aug;64(2):254–6. [PubMed] [Google Scholar] Reference #2: Francois B, Desachy A, Cornu E, Ostyn E, Niquet L, Vignon P. Traumatic pulmonary hernia: surgical versus conservative management. J Trauma. 1998;44:217–9. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Ali Alkhayat, source=Web Response No relevant relationships by Amir Khan, source=Web Response No relevant relationships by Kamran Manzoor, source=Web Response No relevant relationships by Gary Schwartz, source=Web Response