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Intercostal lung hernia

An intercostal lung hernia is defined as protrusion of the lung beyond the confines of the thoracic cage. It is an uncommon entity. 

Pathology

Classification

Lung hernias are classified by their anatomic locations and the mechanism by which they arise (congenital or acquired).  

Location 
  • cervical : ~ 35%
  • intercostal : 60 - 83%
  • diaphragmatic : extremely rare

They can be either congenital or acquired in origin (classified by Morel-Lavallee in 1847). Acquired types are sub divided into pathologic, inflammatory or traumatic. Most lung herniations are of the thoracic intercostal type and are a result of trauma or post thoracotomy incision 3.

Cervical hernias result from protrusion of the lung through the anterior region of the thoracic inlet where there is a space between the scalenus anterior and sternocleidomastoid muscles. Cervical hernias that are congenital in origin often resolve spontaneously. Acquired cervical hernias are more common and are mostly seen in elderly patients with emphysematous lungs with weak cervical fascia. Direct trauma, weight lifting and playing wind instruments can lead to a supraclavicular bulge in individuals with such fascial defects. Coughing and the valsalva maneuver are capable of enlarging the bulge 2.

Intercostal hernias are a result of weakening of the thoracic wall or abnormally elevated intrathoracic pressure as seen in weight lifters and those who play wind instruments. Acquired intercostal hernias are most common and are usually due to trauma or inflammatory processes. In post traumatic cases, the lung herniation may occur immediately after the impact or years later.

Treatment and prognosis

Asymptomatic lung hernias may be managed by close observation. Hernias which are symptomatic may cause dyspnea, chest wall pain or a visible or palpable chest bulge (most common in intercostal lung hernias). In such cases, immediate reduction and closure of the defect is indicated to prevent incarceration and strangulation 3.

Although lung hernias are rare and usually benign in nature, it is important for physicians to be aware that these entities do exist so that they are not alarmed when they are encountered. Knowledge of the benign nature of lung hernias will prevent the use of unnecessary invasive procedures and surgery.

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