Interact CardioVasc Thorac Surg 2008;7:1210-1211. doi:10.1510/icvts.2008.189852
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Extrathoracic herniation of a lung bulla through a tube thoracostomy site
Erdal Okur*,
Cagatay Tezel,
Volkan Baysungur and
Semih Halezeroglu
Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital, D Blok, Maltepe, Istanbul, 34758, Turkey
Received 31 July 2008;
received in revised form 8 September 2008;
accepted 9 September 2008
Corresponding author. Tel.: +90 532 7961600; fax: +90 216 4214265.
E-mail address: erdalokur{at}hotmail.com (E. Okur).
 |
Abstract
|
|---|
We report a case of lung bulla herniation occurring two years after a tube thoracostomy application due to pneumothorax. A new bulla can develop or a pre-existing bulla can herniate through a weak part of thoracic wall, a tube thoracostomy site as in our case. Diagnostic and radiological features of this uncommon case are described.
Key Words: Bulla; Lung herniation; Tube thoracostomy
|
1. Introduction
|
|---|
Lung herniation is defined as the protrusion of the pleura-covered lung through the thoracic wall. It can be congenital or acquired. Herniation of the bulla is a very rare type of lung herniation and only a few such cases have been reported in literature.
|
2. Case
|
|---|
A 45-year-old man was referred to us for a soft retractable mass on his left lateral chest wall. He had a 45-pack-year smoking history and was receiving follow-up treatment for chronic obstructive pulmonary diseases (COPD). He also had a history of having had spontaneous pneumothorax for which chest tube placement was performed two years ago. On physical examination, a palpable and retractable mass that changed its size with inspiration and expiration and was located at the 5th intercostal space on the anterior axillary line was observed. Scar of previous tube thoracostomy incision was observed on the skin overlying the mass (Fig. 1). Chest X-ray revealed a round air cyst lesion outside the thoracic cage. Subsequently, we performed computerized tomography (CT) to acquire a better demonstration of the lesion. The CT image revealed an intrathoracic bulla abutting the left lateral pleural wall and its neighborhood; in addition, the CT image also revealed an extrathoracic bulla (Fig. 2). Based on the history of the patient, the results of physical examination and the radiological findings, we thought that both the bullae interacted with each other through a hole in the intercostal space. This hole was the site where the previous tube thoracostomy was performed. Under general anesthesia, a left lateral thoracotomy incision was made over the lesion. After careful dissection of the subcutaneous tissue, an extrathoracic bullous lesion was revealed. The bulla was connected to the intrathoracic space via a narrow 1-cm neck extending through the intercostal space. The intercostal muscle was divided and the bulla was excised using a mechanical stapler. In order to prevent recurrent herniation, the ribs were tightly approximated. The postoperative course was uneventful. At the 6th month of follow-up, the patient presented no symptoms.
View larger version (104K):
[in this window]
[in a new window]
|
Fig. 2. (a) Chest X-ray shows a cystic lesion that extends into the subcutaneous tissue. (b) Computed tomography demonstrates herniation of the bulla.
|
|
|
3. Discussion
|
|---|
Thoracic lung herniation can be congenital or acquired, such as following an injury or surgical intervention. However, herniation of emphysematous bullae is extremely uncommon. In the literature, we could find only three cases of bulla herniation; of these, two were cases of extrathoracic herniation and occurred at the previous tube thoracostomy site, and the other was defined by the herniation of a bulla into the mediastinum [1–3].
Due to the nature of the emphysematous lung in COPD patients and the increased intrathoracic pressure generated during coughing bouts, this can cause herniation of the soft lung parenchyma through a weak site in the intercostal space and subcutaneous tissue. The previous tube thoracostomy site, which is mostly located in the lateral chest wall where extrathoracic muscular support is minimal (auscultatory triangle), is a potential weak site where bulla herniation can occur. In theory, thoracoscopic port sites can also possess some potential risk of herniation.
It is important to differentiate an extrathoracic herniation of a bulla from a soft tissue neoplasm, a cyst, or an abscess of the chest wall. Needle aspiration biopsy, mostly performed for the diagnosis of these pathologies, can be dangerous and cause pneumothorax in patients with bulla herniation. An increase in the size of the chest wall mass by the Valsalva maneuver and a decrease in its size by the Muller maneuver provide clues pertaining to the disease. Radiological examination is required for the detection of the exact localization, size and assessment of the underlying lung parenchyma.
Conservative treatment using pads and corsets or surgical excision has been suggested, depending on the etiology, size, location and respiratory status of the patient with lung herniation [4, 5]. However, in our opinion, in cases of extrathoracic herniation of bullae, surgical excision is required since this lesion can easily rupture spontaneously.
In conclusion, a possibility for the extrathoracic herniation of the bullous lung should be remembered during the differential diagnosis of soft chest wall masses, especially if the patient has a history of previous chest tube application or thoracoscopy. In thin and muscularly weak individuals, chest tube or thoracoscopy port sites should be tightly closed in order to prevent the development of extrathoracic bulla herniation.
|
References
|
|---|
- Rathinam S, Collins FJ. Bullous herniation of the lung through an intercostal drain site. Eur J Cardiothorac Surg 2003;23:240.[Free Full Text]
- Konecny JA, Grosso MA, Fernandez J, Murphy D, McGrath LB. Images in cardiothoracic surgery. Herniation of emphysematous bulla through a chest tube site. Ann Thorac Surg 1999;68:584.[Free Full Text]
- Ohsaki Y, Akiba Y, Imamoto C, Ohki Y, Sakai E, Haneda T, Onodera S, Nakajima S, Kubo Y. A case of successful surgical removal of giant bulla with mediastinal herniation. Nihon Kyobu Shikkan Gakkai Zasshi 1987;25:1346–1350.[Medline]
- Sonett J, O'Shea M, Caushaj P, Kulkarni M, Sandstrom S. Hernia of the lung: case report and literature review. Ir J Med Sci 1994;163:410–412.[CrossRef][Medline]
- Temes RT, Talbot WA, Green DP, Wernly JA. Herniation of the lung after video-assisted thoracic surgery. Ann Thorac Surg 2001;72:606–607.[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction